(May 2004) With the 2003 outbreak of severe acute respiratory syndrome (SARS) demonstrating that China needed to expand its efforts to prevent and control the spread of infectious diseases, the country’s national response to HIV/AIDS has seen dramatic progress. The national government has taken a number of steps that represent an increasing willingness to address complex social and political issues linked to the HIV/AIDS epidemic. However, with official estimates of people living with HIV/AIDS rising from 500,000 in 1999 to 1 million by 2002, China continues to face a number of challenges as it strives to contain a large and growing crisis that experts fear could affect more than 10 million people by 2010.1
Three Distinct Epidemics
China’s HIV/AIDS crisis is unique, compared with epidemics in other parts of the world. The country faces not one, but three distinct epidemics that are found mainly in rural areas and among marginalized populations engaged in illicit activities.2 The population that has received the preponderance of government attention to date comprises people infected through unsafe blood donation practices who are concentrated in seven central provinces, including Henan, and in isolated villages elsewhere.
The second HIV/AIDS epidemic is occurring among intravenous drug users (IDUs), who accounted for half of all reported HIV cases in 2002.3 This epidemic is occurring primarily in provinces along the western and southwestern border, including Yunnan, Xinjiang, Guangxi, and Sichuan, although all 31 provinces have reported HIV infection among IDUs.
The third epidemic is occurring through sexual transmission, spreading to the general population from high-risk groups, such as IDUs, female sex workers and their clients, and highly mobile domestic economic migrants. The proportion of HIV infections that were sexually transmitted increased from 5.5 percent in 1997 to 11 percent by the end of 2002, raising concerns that this third epidemic will overtake the others.4 Studies indicate that high-risk behavior is occurring widely, both among high-risk groups and in the general population. Large numbers of female sex workers report that they never use condoms, while young people in urban areas increasingly engage in premarital sex with multiple partners.5 Studies also indicate increases in sexually transmitted infections (STIs) in the general population.6 In addition to being serious illnesses, STIs facilitate the sexual transmission of HIV infection.7
These three distinct epidemics present diverse challenges to attempts to develop a coordinated national response, requiring not only different medical and public health interventions, but complex social and legal responses as well. Regardless of the nature of the epidemics, the global experience indicates that committed, top-level leadership as well as the involvement of other levels of government are key elements of any successful national effort to contain the spread of HIV/AIDS.
China’s current leaders took office between the 16th Party Congress in November 2002 and the National People’s Congress in March 2003 amid much speculation about how they would make their imprint on the country’s domestic and international policies. Immediately after taking up their party and government positions, the leaders faced the outbreak of SARS, the disease that the World Health Organization says began in November 2002 in southern China and spread internationally, affecting some 29 nations. Confronting a public health challenge that had taken more than 900 lives in four countries alone8 and that threatened economic growth and social stability, China’s top leaders mobilized massive resources to control the spread of infection.
By the summer of 2003, the spread of SARS appeared to have ended. By late 2003, top leaders were taking a more visible role on HIV/AIDS prevention and treatment issues — an indication that the lessons learned from SARS would translate into an increased commitment to fighting the AIDS epidemic.
A number of other developments provided evidence of that commitment. In mid 2003, China began to distribute life-prolonging, antiretroviral drugs for free or at reduced prices to former plasma donors in nine provinces in central and northeast China. This showcase treatment program, administered by the Chinese Center for Disease Control is known as the “China CARES” program and benefits from top-level political attention as well as international funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria. By October, approximately 5,000 persons had begun antiretroviral treatment. The program’s ultimate target is to bring 40,000 people under treatment in 120 of China’s some 2,800 counties.9 The Chinese ministry of health estimates that by 2008, some 300,000 AIDS patients will need treatment throughout China.10
A November 2003 visit by former U.S. President Bill Clinton to Beijing to address a summit on SARS and AIDS marked another turning point in the national response to the epidemic. In an event broadcast widely in China, Clinton concluded his talk by putting his arm around a young person living with HIV/AIDS. The moment highlighted the fact that Chinese leaders had yet to take a visible role in the government response to the epidemic and publicly meet with HIV/AIDS sufferers. Less than a month later, Premier Wen Jiabao and Vice Premier and Minister of Health Wu Yi visited AIDS patients at Ditan hospital in Beijing and publicly shook hands with them. Subsequently, the vice premier visited Henan province to inspect an “AIDS village” and meet with residents,11 and later Madame Wu Yi met with prominent AIDS activist Dr. Gao Yaojie to seek her recommendations for helping affected villagers in the province.12
While the ministry of health has been largely at the forefront of efforts to confront the epidemic to date, a lack of coordination between elements of the bureaucracy has hampered the implementation of truly comprehensive programs that address HIV/AIDS as a broad, social problem rather than a primarily medical issue. The State Council, China’s cabinet, created a committee in 1996 that Vice Premier Li Lanqing headed. However, this “State Council Coordinating Committee to prevent and control HIV/AIDS” met only four times, and efforts to rejuvenate it in 2001 failed.13
A new State Council HIV/AIDS Working Committee, which held its first meeting February 16, 2004, includes the vice governors of Guangdong, Guangxi, Sichuan, Yunnan, Xinjiang, Henan, and Hubei provinces.14 Headed by Vice Premier Wu Yi, the committee is to be a stand-alone office within the health ministry and is expected to convene regular meetings of key ministries in the national response to HIV/AIDS.
Also, in April 2004, the State Council called a senior-level national meeting that included governors and representatives of key provincial ministries to announce new HIV/AIDS policies. Key policies include authorization to carry out such “harm reduction” strategies as condom promotion in entertainment establishments and needle exchange programs.
As part of the centerpiece policy, known as “four frees and one care,” the government has committed to provide free antiretroviral drugs to impoverished citizens, free voluntary HIV testing and counseling, free prevention of mother-to-child transmission, free schooling for AIDS orphans, and care for AIDS patients and their families. Provinces and counties are required to raise funds locally to support these mandates. However, since HIV/AIDS is most serious in the poorest regions, it is uncertain if the policies will be successfully implemented where they are needed most.
Challenges to Coordinating a National Response
While China has established prevention and treatment programs for HIV-infected former plasma and blood donors, the country’s national response has fallen short of a more comprehensive approach to addressing the broad issues of other affected and at-risk groups. Former plasma donors, who did not become infected through illicit or “immoral” activities, are relatively easy to identify in villages and townships where they live. Programs for this group include counseling and distribution of free antiretroviral drugs and condoms through AIDS clinics, financial support for orphans, and reductions in the tax burden of farmers who have HIV. These activities require local-level coordination between bureaus, including the ministries of civil affairs, finance, education, and population and family planning.
On the other hand, the government has not yet articulated a national response to the spread of HIV among hard-to-reach and socially marginalized populations, such as IDUs, commercial sex workers and their clients, men who have sex with men, and the “floating population” of economic migrants.
The illicit nature of drug use and commercial sex poses a particular challenge to identifying infected individuals and those at risk within these groups who are also less inclined to voluntarily work with or be identified by government authorities. The national government confronts the challenge of reconciling a morally conservative, traditional approach to governance with a rapidly changing society where illegal activities or actions considered immoral, such as premarital sex, are increasingly widespread. In particular, the government faces the dilemma that it might appear to be condoning drug use or commercial sex by establishing HIV/AIDS treatment and counseling programs without also addressing the fundamentally illegal or “immoral” acts that place these populations at risk.
An unmet challenge is the need to outline and communicate new policies to departments responsible for implementing programs that target marginalized populations. Because of the difficulty of communicating to local officials that commercial sex is anything other than illegal, the national government has found itself unable to move from limited pilot projects to effectively implement a “100 percent condom” campaign targeting commercial sex workers. Outside of notable successes in Yunnan province, there have been no province-wide efforts to market condom use in so-called “entertainment establishments.” Similarly, needle-exchange programs have only recently won the endorsement of the central government, which confronts the same moral objections as many other nations on the issue of illegal drugs.
Migrant workers are also difficult to reach and present a challenge in designing effective education programs. This “floating population” or liudong renkou refers to the estimated 120 million to 130 million rural people who migrate to the cities in search of work. Many migrants have limited education, and many do not speak Mandarin, the main Chinese dialect. Since they typically have no legal status, the migrants receive no social services in the urban areas where they work and are reluctant to engage with government officials. Because migrants do not receive social services in urban areas, families frequently do not accompany the workers, a situation that presents increased opportunities for risky behavior and for the spread of HIV between high-prevalence regions to previously unaffected areas.
Confronting the Challenges
Addressing the needs of marginalized groups while maintaining or expanding top-level attention to the issues is key to any effective national response to the HIV/AIDS epidemic. Ensuring that the new AIDS prevention committee meets regularly may also help ensure that national programs are carefully formulated and implemented. In the meantime, the government has taken other steps that, while limited, represent an increasingly open attitude and a willingness to address complex social issues:
- Chinese health authorities are preparing an application to the Global Fund to Fight AIDS, Tuberculosis and Malaria for funds to incorporate IDUs and commercial sex workers with HIV in southwestern and western provinces into a nationally designed program to provide treatment and prevention counseling.15
- The system of residence permits, or hukou, is slowly being reformed to facilitate more equitable delivery of social services to migrants and their families. These reforms would allow more families to migrate together and provide more legitimate economic opportunities for female migrants who otherwise could be enticed into commercial sex.
- In December 2002, officials announced that a nationwide ban on condom advertisements would be lifted in 2003. In December that year, China Central Television, CCTV, aired the first condom commercial authorized by the central government since a single ad aired in 1998.16 With the ban lifted, television stations have increasingly discussed sensitive issues on air. For example, in April, CCTV aired a two-part story about condom marketing in hotels and entertainment establishments in Yunnan province. The story included an interview with the director of the Yunnan provincial police academy.17
- Sex education is slowly being introduced in secondary schools in some parts of China to educate young people about risks and modes of transmission of HIV.
What the Chinese Government Can Do at the National Level
While these measures and the formation of a national-level working committee under the State Council represent promising steps toward strengthening political leadership and coordinating national prevention and treatment programs, the government could strengthen its response in a number of areas.
The central government could establish a leading small group or lingdao xiaozu on HIV/AIDS to help maintain sustained coordination at the highest levels of government and assist in the development of new policies.
Leading small groups have been formed to address major foreign and domestic policy challenges, including the recent bird flu outbreak, SARS, and schistosomiasis. A lingdao xiaozu made up of politburo members, including Premier Wen Jiabao, would ensure consensus at the highest levels of the party, deepen and broaden commitment at the highest levels of government, provide impetus to the AIDS working committee, and ensure that lower levels are accountable and implementing appropriate policies and programs.
Enacting key legal reforms would also enhance the national effort to prevent the spread of HIV/AIDS and increase economic security and stability for many of China’s citizens. In addition to revising the system of residence permits, other legal reforms could protect the rights of people with HIV. Such rights would include the right to work, the right to have their HIV status kept confidential, and the right to treatment and social services.
The government’s response must also take into account the role of civil society in addressing the HIV/AIDS crisis. Reform of corporate and personal income tax laws could introduce financial incentives for donating to charities. Additionally, increased decentralized economic support for HIV/AIDS would enable more grassroots organizations to take a role in providing social services and implementing interventions to affected populations, particularly those marginalized groups that the government has a hard time reaching.
One overlooked area in the national response is the role of businesses in educating their workers about HIV/AIDS prevention. Foreign invested businesses interested in implementing education programs for their workforces frequently find their local partners and staff resistant to addressing sensitive, personal issues at work. Public statements from senior leaders such as Vice Premier Wu Yi, who is responsible for health issues as well as matters of trade and commerce, would encourage businesses to implement education programs and establish HIV prevention policies as well as policies to address the stigma associated with infection.
While a national-level response and high-level commitment are crucial to containing localized epidemics, implementation at local levels throughout China will be vital to ensuring the country’s long-term health and economic growth and stability.
Drew Thompson is a research associate with the Freeman Chair in China Studies at the Center for Strategic and International Studies (CSIS) in Washington, DC. Mr. Thompson has traveled extensively throughout China and speaks, reads, and writes Mandarin.
- China Ministry of Health and United Nations Theme Group on HIV/AIDS in China, “Joint Assessment Report on HIV/AIDS Prevention and Control in China: Dec. 1, 2003,” accessed online at www.unaids.org/en/in+focus/topic+areas/prevention.asp on April 22, 2004.
- World Health Organization (WHO), HIV/AIDS in Asia and the Pacific Region 2003 (Geneva: WHO, 2003): 52.
- China Ministry of Health and the United Nations Theme Group on HIV/AIDS in China, “Joint Assessment Report on HIV/AIDS Prevention and Control in China: June 17, 2003,” accessed online at www.youandaids.org/unfiles/joint_assessment_exec_summary_china.doc on April 30, 2004.
- China Ministry of Health and the United Nations Theme Group on HIV/AIDS in China, “Joint Assessment Report: Dec. 1, 2003.”
- China Family Planning Association, China Youth and Unmarried Youth Growing up Healthy: Research Results Literature Review (Beijing: China Population Press, 2002). This literature review (in Chinese) contains abstracts of 192 studies from 1994 to 2001, with the majority from the 1999-2000 period. See the summary on page 16 regarding knowledge and attitudes, and condom knowledge from pages 19 to 21.
- China Ministry of Health, “2003 Legally Reportable Infectious Disease Appraisal Statistics” (in Chinese), accessed online at www.moh.gov.cn/dsyyw/yqfb/1200402180005_1_0.xls on April 30, 2004.
- World Health Organization (WHO), “Global Prevalence and Incidence of Selected Curable Sexually Transmitted Infections: Overview and Estimates” (Geneva: WHO, 2001).
- WHO, “Severe acute respiratory syndrome (SARS): Report by the Secretariat to the WHO Executive Board,” November 27, 2003, accessed online at www.who.int/gb/EB_WHA/PDF/EB113/eeb11333.pdf on April 30, 2004.
- China’s Country Coordinating Mechanism, “China CARES (Comprehensive AIDS Response): A Community-Based HIV Treatment, Care, and Prevention Program in Central China,” Round 3 HIV Proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria, June 2003.
- China’s Country Coordinating Mechanism.
- “Vice-premier visits Henan AIDS patients,” China Daily, Dec. 24, 2003.
- “Top Chinese Leader met with country’s most famous AIDS activist,” Agence France-Presse, Feb. 18, 2004.
- J. Stephen Morrison and Bates Gill, eds., Averting a Full-blown HIV/AIDS Epidemic in China: A Report of the CSIS HIV/AIDS Delegation to China, January 13-17, 2003 (Washington, DC: CSIS Press, 2003): 7.
- “National Committee Set Up to Beef Up AIDS Prevention,” China Daily, Feb. 27, 2004.
- Discussions with health officials in China in February and March, 2003.
- “Gov’t-approved Condom Ads Air for First Time,” China Daily, Nov. 28, 2003.
- CCTV.com, transcript of the television interview, accessed online at www.cctv.com.cn/news/china/20040408/100428.shtml on April 30, 2004.