(July 2004) Increases in the heterosexual transmission of HIV in China are fueling concerns—including among senior Chinese leaders—that the epidemic may be moving from specific regions and at-risk groups into the general population, where the virus could more easily prey on women’s vulnerabilities.1 China’s HIV/AIDS prevention efforts have accordingly begun to address sexual transmission of the disease. But broad and targeted interventions that emphasize women in their approach—including education and access to opportunity—will be essential to preventing a generalized epidemic in the country.2
The Rise of Sexually Transmitted HIV in China
China’s HIV/AIDS epidemic has mainly affected intravenous drug users in the country’s southwestern provinces as well as rural people in central China who had sold blood and plasma in the 1990s to commercial collection centers. While plasma donations and intravenous drug use still accounts for the vast majority—an estimated 70 percent—of China’s HIV infections,3 the proportion of the country’s infections that occur through sexual contact has been rising. Sexually transmitted infections increased from 5.5 percent in 1997 to 11 percent by the end of 2002.4
Another sign that the epidemic may be spreading sexually is the rise in new infections among women when compared with increases among men. The British Department for International Development (DFID) reports that, in 1990-1995, the male-female ratio of people living with HIV/AIDS was 9 men to 1 woman. Estimates in 2001 showed the gap had narrowed to roughly 3.4 men to 1 woman.5 More recent estimates reflect a similar pattern: for example, a joint assessment by the Chinese Ministry of Health and the Joint United Nations Programme on HIV/AIDS (UNAIDS) shows that the ratio of reported infections went from 5 men to 1 woman during 1995-1997 to 4 men to 1 woman by 2001.6
Indeed, global experience has shown that HIV/AIDS epidemics affect increasing numbers of women as time progresses. In 1997, 41 percent of adults living with HIV/AIDS worldwide were women.7 Today, women constitute close to half of the 37.8 million people living with the virus.8 Some 57 percent of infected adults in sub-Saharan Africa are women, and in North America, the percentage of HIV-infected women rose from 20 percent in 2001 to 25 percent in 2003.9
The epidemic in China—where national HIV prevalence is less than half a percent—reflects this trend. While still mainly affecting at-risk groups, the epidemic in the world’s most populous country is increasingly affecting women as the virus exploits new opportunities for transmission.
Chinese Women: Particularly Vulnerable to Infection
A number of physiological, social, cultural, and economic factors interact to influence the health of communities and individuals. Women and girls are particularly vulnerable to HIV infection because of biological differences between men and women. Far more significant, however, are the socially defined differences between men and women that hinder a woman’s ability to avoid the risks of infection.
Physical Vulnerabilities and Soaring STI Rates
Anatomical differences make transmission of the virus through sexual contact far more efficient from men to women than vice versa. Research shows that the risk of infection with HIV during unprotected sex is 2-4 times higher for women than for men. This is primarily because the lining of a woman’s vagina and cervix contains a large area of mucous membranes—thin tissues through which HIV and other viruses can pass to tiny blood cells. Infected semen also typically contains higher concentrations of the virus than a woman’s sexual secretions.
Women are also more susceptible than men to other sexually transmitted infections (STIs), which often go undetected in women. If either partner has an STI, the risk of HIV infection through sexual intercourse increases dramatically. In China, STIs have increased rapidly since the mid-1980s. Reported cases of STIs soared from 5,800 in 1985 to 836,000 in 1999.10 However, Chinese experts estimate that only about 10 percent of sexually transmitted infections are captured by the national STI reporting system, since many sufferers seek treatment in discreet, private clinics.
High rates of STIs in the general population also provide important indications about the presence of high-risk behavior and are an epidemiological marker for HIV/AIDS.11 The results of a 2000 national survey of chlamydia infection in China suggest that the greatest risk for sexually active women under the age of 45 is to be married or in a long-term relationship with a man, indicating that the high-risk sexual behavior of unfaithful spouses places more women at risk than their own behavior.12
Migration, Sex Work, and the Education Deficit: Women’s Social Vulnerability in China
Social changes in China over the last two decades have changed the risk environment for a majority of Chinese and Chinese women in particular. While economic development has benefited many since the country began reforming its economy and opening its doors to foreign trade in 1979, the government no longer provides universal services, personal mobility has increased, and illicit behaviors such as commercial sex and drug use are on the rise.
With the elimination in China of food-ration coupons in the 1980s and the decreasing importance of state-owned enterprises that offer workers security and benefits, Chinese people have increasingly left their places of residence for other parts of the country in search of work. The closing of many Chinese state-owned enterprises has also allowed a private sector economy to flourish there, providing new economic opportunities, particularly in urban areas. Because of this increased freedom of movement, millions of rural people, many of whom have little other than agricultural skills and experience, have left their villages.
Migrants, however, represent one of the most vulnerable groups with regards to HIV infection. In China, those who leave for cities in search of work are mainly young, often poorly educated, and at sexually active stages of their lives. Lacking any health insurance or social welfare programs, these migrants have little access to HIV prevention information and basic health care. Far from the social constraints of their homes, migrants join new peer groups, including sexual networks. Migrant women and girls are often more vulnerable than their non-migrant counterparts to some kind of transactional sex as they try to negotiate employment, food, or a place to live.
Commercial sex represents an area of high risk for the sexual transmission of HIV. For women with limited education or job skills, sex work can be a lucrative alternative to manual or semi-skilled labor in factories or on job sites. Some estimates place the number of sex workers in China at around 3 million.13 However, others such as Professor Pan Suiming of People’s University in Beijing believe the numbers of women who engage in casual or infrequent transactional sex to be considerably higher.14
Condom use is low among Chinese sex workers and their clients. Female sex workers often lack either the power to insist on the use of condoms with their clients or knowledge of the risks of unprotected sex. Data collected at various sites in the country show that only about 10 percent of sex workers reported that they always use condoms, while close to half said they had never used condoms.15
Many sex workers and their clients are unaware of the risks of unprotected sex, particularly the transmission modes and consequences of STIs including HIV. Also, because of the illegal nature of their work, commercial sex workers are difficult for health workers to identify and reach, hindering efforts to educate these workers about HIV/AIDS, distribute condoms, or test them for HIV and other STIs.
Limited education also heightens the risks for women, undermining their self-confidence, status, and ability to find employment and other opportunities. The education system is a key area where China’s evolution from a centrally planned to a more free-market system may be increasing male-female disparities.
Expenditures by the central government on education are inadequate to cover the costs of education, forcing provinces and the localities to make up the gaps. In 2000, China spent 2.2 percent of gross domestic product on education—below the 3.2 percent average for East Asian developing countries.16 Education provision is therefore highly dependent on the fiscal capacity of individual localities, which inevitably have to charge fees to students to cover expenses.
But many families with limited resources are unable to provide school fees, causing many children to drop out before the nine years of education stipulated in the Chinese constitution. For families with more than one child, a traditional preference for boys means that a daughter’s education is more likely to be cut short than that of a male sibling. One survey found that 87 percent of females drop out of school before age 15, compared with 40 percent of males.17 In 2002, women’s illiteracy in China was 22.9 percent, compared with 7.9 percent for men.18
Latest Government Efforts Begin Targeting Women
As the HIV/AIDS epidemic matures and evolves in China, interventions that emphasize women are essential. The central government has proposed a number of policies to address HIV/AIDS, particularly in the most effected populations of former plasma donors, injecting drug users, and commercial sex workers.
China’s most recent application to the Global Fund to Fight AIDS, Tuberculosis and Malaria focuses on providing treatment and care to injecting drug users and commercial sex workers in seven of the country’s southwestern provinces. Money for the first two years of the project, totaling $24 million, has been tentatively approved.19 Increased funding and a commitment to reach out to sex workers may improve opportunities to test and educate this marginalized group to prevent the spread of HIV.
The country’s “four frees and one care” policy also represents a significant step by the government to reach out to all HIV sufferers, regardless of how they became infected. The policy aims to provide free voluntary testing and counseling, free antiretroviral drugs, free prevention of mother-to-child transmission, free schooling for AIDS orphans, and care for AIDS patients and their families.
Corresponding policy developments have taken place at local and provincial levels, reflecting this increased national attention and commitment to the pandemic. For example, Yunnan province in Southwest China recently implemented the country’s first “AIDS law,” which requires hotels and entertainment establishments to display information about the transmission of HIV/AIDS and make condoms available to employees and patrons.20
Beginning in 2001, two local projects (in Wuhan, Hubei province in central China and Jingjiang, Jiangsu province in the east) also implemented pilot programs to promote condom use in entertainment establishments, but the programs have yet to be expanded and implemented throughout those provinces.21 Encouraging other provinces to follow Yunnan’s lead and mandate “100 percent condom campaigns” or similarly appropriate measures should be a top priority for central government policymakers.
In the long term, ensuring basic education for young people—particularly young girls—could have a considerable strategic impact on China’s fight against the sexual spread of HIV/AIDS. Educating and empowering young women through improved access to education, information, and economic opportunities will enable them to be more productive members of society. Education and access to opportunity will also ensure their rights and access to healthcare and resources that may ultimately reduce their vulnerability to the risky behaviors and conditions that facilitate the spread of HIV/AIDS.
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.
- Bates Gill et al., “Defusing China’s Time Bomb: Sustaining the Momentum of China’s HIV/AIDS Response,” (Washington, DC: Center for Strategic and International Studies, 2004), accessed online at www.csis.org/china, on July 26, 2004.
- The “general population” refers broadly to persons who do not engage in high-risk activities such as intravenous drug use or commercial sex. The term general population should not be confused with a “generalized epidemic,” which UNAIDS describes as present when HIV prevalence reaches one percent in the general adult population. In China’s case, a generalized epidemic would entail approximately 8 million HIV infections.
- World Health Organization (WHO), HIV/AIDS in Asia and the Pacific Region: 2003 (Geneva: WHO, 2003).
- China Ministry of Health and the United Nations Theme Group on HIV/AIDS in China, “Joint Assessment Report: Dec. 1, 2003,” accessed online at www.unaids.org/EN/other/functionalities/Search.asp, on July 26, 2004.
- Susie Jolly with Wang Ying, “Key Issues on Gender and HIV/AIDS in China” (report for U.K. Department for International Development, Jan. 27, 2003).
- UNAIDS and Chinese Ministry of Health, “Joint Assessment”: 8.
- Joint United Nations Programme on HIV/AIDS (UNAIDS) and WHO, AIDS Epidemic Update: December 1998 (Geneva: UNAIDS and WHO, 1998).
- UNAIDS, 2004 Report of the Global AIDS Epidemic (Geneva: UNAIDS, 2004), accessed online at www.unaids.org/bangkok2004/report.html, on July 26, 2004.
- UNAIDS, 2004 Report of the Global AIDS Epidemic.
- WHO, HIV/AIDS in Asia and the Pacific Region: 2003. See also X. Gong et al., “Epidemiological analysis of syphilis in China Through 1985 to 2000,” Chinese Journal of Sexually Transmitted Infections 1 (2001): 1-6. See also U.S. Centers for Disease Control, “Report of an HIV/AIDS Assessment in China” (2001), accessed online at www.usembassy-china.org.cn/sandt/ptr/CDCAssessment-prt.htm, on July 26, 2004.
- Chris Beyrer, “Hidden Epidemic of Sexually Transmitted Diseases in China: Crisis and Opportunity,” JAMA 289 (2003): 1303-05. See also R. Detels et al., “Sexually transmitted disease prevalence and characteristics of market vendors in eastern China,” Sexually Transmitted Diseases 11, no. 30 (Nov. 30, 2003): 803-8.
- W.L. Parish et al. “Population-based study of chlamydial infection in China: a hidden epidemic.” JAMA 289 (2003):1265-73. The article is based on a 2000 study of a national stratified probability sample of 3,426 Chinese individuals.
- WHO, HIV/AIDS in Asia and the Pacific Region: 2003.
- Pan Suiming, conversation with author, April 2004.
- WHO, HIV/AIDS in Asia and the Pacific Region: 2003.
- World Bank, “Edstats Summary Education Profile for China,” accessed online at http://devdata.worldbank.org on July 2, 2004.
- Zhang, Weiguo, “Rural Women and Reform in a North Chinese Village,” in Village Inc.: Chinese Rural Society in the 1990s, eds. Flemming Christiansen and Zhang Junzou (Honolulu: University of Hawaii Press, 1998): 206.
- DFID report, page 5. See also World Bank Group, China Data Profile (http://devdata.worldbank.org).
- Global Fund to Fight AIDS, Tuberculosis and Malaria, “Portfolio of Grants in China,” accessed online at www.theglobalfund.org/search/portfolio.aspx?countryID=CHN#HIV/AIDS, on July 26, 2004.
- Order of the People’s Government of Yunnan Province No. 121, “Yunnan Sheng Aizibing Fangzhi Banfa” (Responsive measures for HIV/AIDS prevention in Yunnan province), articles 12, 13 and 24, accessed online at www.yn.xinhuanet.com/ylfzh/fagui/2004/021001.htm, on July 26, 2004.
- See UNAIDS, “Join the Fight Against AIDS in China,” accessed online at www.unaids.org/html/pub/Topics/Partnership-Menus/ PDF/CHINAcover_en_pdf.pdf, on July 26, 2004.