PRB

(April 2003) China is at significant risk of a generalized HIV/AIDS epidemic as the disease is spreading from relatively localized high-risk groups into the mainstream population. The Chinese government had documented 40,560 cases of HIV infection by the end of 2002 but estimates that 1 million are infected nationwide. Outside experts, including the U.S. National Intelligence Council and the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimate that by 2010 there could be between 10 million and 15 million infected Chinese.

The Chinese government has identified three localized HIV/AIDS epidemics in China: approximately 68 percent of those with HIV are identified as intravenous drug users, located largely in the south and west; 10 percent were infected through heterosexual intercourse identified largely as commercial sex workers and their clients; and 10 percent were infected through unsafe blood donation practices. How the remainder contracted the disease is unclear. These relatively well-defined, vulnerable populations have regular contact with so-called “bridge populations” who have great potential to spread HIV, particularly as China’s economy continues to reform and the population becomes increasingly mobile.

“Bridge Populations” Can Spread HIV Nationwide

One of the key bridge populations is the “floating population” (liudong renkou), the estimated 120 million to 130 million rural people who migrate to the cities in search of work. The floating population is extremely vulnerable to HIV infection. They are largely young, poorly educated, in the sexually active period of their lives, but they have little access to prevention education. Male migrants make up the largest proportion of the floating population and are frequently away from home for 50 weeks a year, living in single-sex dormitory housing, and working long hours in difficult conditions.¹ They are easy targets for drug sellers and have ample opportunities to interact with sex workers. Being far from home, they are also less constrained by the conservative mores of their home villages.

Migrants constitute a large number of commercial sex workers, who are generally young and have little formal education. Sex education is not taught in primary or middle schools in China, and cultural conservatism limits discussion of sexual matters within families. The Chinese Ministry of Health estimates that 1.3 percent of sex workers had HIV in 2002. Other experts have estimated that the infection rate is almost 11 percent and 5 percent in Guangxi and Yunnan provinces, respectively.² There is low condom use and low awareness or knowledge of HIV transmission among sex workers.³ Also, sex workers tend to be very mobile, as are many of their migrant clients.

As the commercial sex industry expands, its clientele increasingly includes middle-class men, business people, and government officials. Recent corruption scandals in China have detailed the use of “sexual bribery” as a common mode of remunerating government officials in lieu of cash payments that could be used as evidence of graft. As HIV infection becomes more prevalent within the commercial sex worker population, China’s most productive working age population, including government leaders, will likely be increasingly affected.

Another key bridge population is long-distance truck drivers who have ready access to commercial sex. Brothels posing as restaurants line interprovince highways outside cities as a kind of “rest stop” for long-haul truckers. Migrants and truck drivers frequently return home to be with partners whose sexual fidelity is also not ensured.

HIV/AIDS is likely to have a major impact on China’s economy since productive workers are most affected. The result could be lower productivity, increased numbers of orphans and childless seniors, and additional social welfare burdens. The United Nations estimates, for instance, that there were 76,000 orphans in China at the end of 2001. By 2010, the number could increase to 280,000. Chinese and European experts estimate that the social and economic burden of HIV/AIDS will increase over time as the epidemic continues to spread.

Government Action To Curb Spread

Unless the government takes action more quickly, HIV/AIDS will spread from localized “high-risk” groups into the general population. China is clearly moving forward in its approach to HIV/AIDS, as the central government begins to take up the issue, mobilize and allocate resources to treat sufferers, and educate the general population about prevention. In 2001, the Ministry of Health — the lead government agency tackling the HIV/AIDS issue — formed a Center for Disease Control and Prevention, adopted a five-year action plan, and increased government spending at the national and provincial levels. The safety of national blood banks has been increased through a RMB 1.5 billion (US$181 million) government bond issue, and China’s 2001 budget for HIV/AIDS prevention and treatment increased to RMB 100 million per year (US$12 million). From 1990 to 1995, annual spending by the central government on HIV/AIDS was estimated to be around $500,000 per year, reaching approximately $1.8 million per year from 1996 to 2000.⁴ While these figures represent significant increases, analysts question whether the amount is adequate. For instance, UNAIDS notes that in 2000, the funds that China allocated to HIV/AIDS prevention and control was one-seventh of the funds that Thailand invested.⁵

Internationally- and domestically-funded pilot programs have been undertaken to help prevent the spread of HIV and treat the sufferers. Grassroots organizations are creatng peer-education groups, and even small groups of independently organized college students are traveling to the countryside to teach prevention and raise awareness. International NGOs, foreign governments, and the UN are all active in China and have invested significant funds and expertise in addressing the epidemic. Most important, the Chinese government has expressed a willingness to work with the international community to create policies and programs that will prevent HIV/AIDS from becoming a disaster.

A Challenge to China’s Infrastructure

Despite a more open and stepped-up response, however, China’s infrastructure is inadequate to the task. Chinese government authorities have been disengaging from public health care services since reform of the economic system began in 1979. Moreover, the Ministry of Health lacks the budget and political support from the senior-most leaders in Beijing. The National Coordinating Committee on HIV/AIDS and Sexually Transmitted Diseases, a committee set up in 1996 to coordinate the activities of 34 separate ministries under the State Council chaired by Vice Premiere Li Lanqing, has met only four times.

The Ministry of Health also faces bureaucratic resistance from provincial authorities, who see HIV/AIDS as a politically sensitive issue with the potential to affect foreign investment and tourism as well as prospects for personal promotion. Many of the central government’s mandates are not funded, resulting in even less compliance from local officials, who sometimes actively resist oversight or provide inaccurate data.

In addition, poor baseline data present a major problem for Chinese officials charged with assessing the problem and allocating resources. China’s HIV surveillance system focuses largely on high-risk populations, especially intravenous drug users and commercial sex workers. Of the approximately 150 national surveillance sites, 63 monitor people with sexually transmitted infections, 38 monitor drug users, and 34 monitor sex workers, while only nine sites monitor long-distance truck drivers.⁶ There are no sites that provide voluntary, confidential testing services to the general public. This lack of accurate surveillance leads people to believe that HIV/AIDS only affects marginalized populations and deprives the Ministry of Health of the hard data to convince skeptics and top leaders that HIV/AIDS poses a serious threat to the general population.

China’s national health care system is also unprepared medically to treat and care for citizens with HIV. The Ministry of Health reports that there are only between 50 and 100 doctors in China able to diagnose and treat HIV infection, and they are rarely in rural areas where the majority of sufferers reside. Only two hospitals in China, both in Beijing, have wards for HIV/AIDS treatment.⁷ Outside of major cities, hospitals and clinics still regularly reuse needles and medical equipment, contributing to the spread of blood-borne diseases. A 1999 study found only one-third of 3,066 village immunization stations actually followed safe injection practices, resulting in 88 percent of injections being unsafe.⁸

Chinese government policies currently emphasize treatment of HIV/AIDS sufferers by locally producing more affordable antiretroviral (ARV) treatments and negotiating reduced prices for patented ARVs produced by multinational pharmaceutical companies to create “cocktail” treatments to suppress HIV. The price of imported and Chinese-produced medications are still well beyond the reach of the vast majority of Chinese who have the virus. Additionally, the prescription of the ARV cocktails is extremely complicated and if drug regimens are not properly followed and monitored by trained personnel and strictly adhered to by patients, resistant strains of HIV invariably develop, quickening the onset of AIDS. If these resistant strains are transmitted to others, drug treatment becomes all the more difficult.

While Chinese officials and media have repeatedly emphasized affordable access to ARVs as a priority in the fight against AIDS, inadequate attention has been paid to developing medical training programs and infrastructure, and little effort has been made to effectively use existing off-patent medicines for treating opportunistic infections. Without trained doctors to diagnose HIV, accurately prescribe medicines, and monitor patient status, access to ARVs may do more harm than good.

China faces a serious HIV/AIDS epidemic that has the potential to become a national disaster. If the government does not act quickly and decisively, China risks becoming the country with the largest number of people with HIV. The international community, including the UN, the World Bank, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and key foreign governments, are prepared to work with China to help stem the spread of HIV. For its part, the Chinese government has expressed willingness to work with international agencies to begin pilot projects in various localities and to build up health care capacity in the capital and the provinces.

Andrew 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. 

References

1. Xinhua, “China Warned of AIDS Epidemic in Floating People,” Jan. 29, 1999. See also U.S. Embassy Beijing, “AIDS in China: A View from the Ministry of Public Health” (April 1997), accessed online at www.usembassy-china.org.cn/english/sandt/webads2.htm, on March 1, 2003.
2. Joan Kaufman, “HIV/AIDS in China: Can Disaster be Averted?” (prepared statement at Roundtable before the Congressional-Executive Commission on China, Washington, DC, Sept. 9, 2002).
3. Wu Zunyou, National Center for AIDS/STD Prevention and Control, Chinese Center for Disease Control and Prevention (presentations made in Washington, DC, in October 2002 and Beijing, in January 2003).
4. Joint United Nations Programme on HIV/AIDS (UNAIDS), UNAIDS Country Profile: China, accessed online at www.unchina.org/unaids/
   
   ekey2.html, on March 1, 2003.
5. UN Theme Group on HIV/AIDS in China, HIV/AIDS: China’s Titanic Peril — 2001 Update of the AIDS Situation and Needs Assessment Report (Geneva: UNAIDS, June 2002).
6. Lu Fan, National Center for AIDS/STD Prevention and Control, Chinese Center for Disease Control and Prevention, “HIV/AIDS Surveillance in China” (presentation in Beijing, Jan. 14, 2003).
7. Figures provided to members of a Center for Strategic and International Studies-led delegation to Beijing, Jan. 13-17, 2003.
8. Figures cited here are from J.K. Zhou et al., “Study on the Safe EPI Injections and its Influencing Factors,” Chinese Journal of Epidemiology 20, no. 6 (December 1999). 

For More Information

Chinese Ministry of Health www.moh.gov.cn

Chinese Center for Disease Control and Prevention www.chinacdc.net.cn/

National Center for AIDS/STD Control and Prevention www.chinaids.org.cn/

UNAIDS China Office www.unchina.org/unaids/

CSIS Freeman Chair in China Studies www.csis.org/china/