HIV/AIDS in China

History

Global background

HIV evolved from the simian immunodeficiency virus (SIV), present in numerous species of primates in West Africa and Central Africa, in the early 20th century. SIV jumped from primates to humans several times, although the primary strain of HIV responsible for the global pandemic, HIV-1 group M, is traceable to the region surrounding Kinshasa, likely having initially crossed from chimpanzees around 1920. From there, it spread to the Caribbean around 1967, proceeding to establish itself in New York City and San Francisco circa 1971 and 1976, respectively.

The US Centers for Disease Control and Prevention (CDC) recognized unusual outbreaks of opportunistic infections among gay men in 1981, and the disease was initially referred to as gay-related immune deficiency (GRID), although it was quickly understood to also infect heterosexuals as well. In 1982, the CDC adopted the name "acquired immune deficiency syndrome" (AIDS). By the end of 1984, 7,699 cases of AIDS and 3,665 deaths had been recorded in America, with an additional cases 762 in Europe. By the end following year, over 20,000 cases were recorded globally, reaching every inhabited region in the world.

Early stages of the epidemic in China

The first recorded death in China due to AIDS was a male Argentine-American tourist and California resident who died in Beijing on 6 June 1985. The Chinese government focused initially on preventing foreigners from transmitting the disease to its citizens, viewing it primarily as a consequence of a Western lifestyle.

By 1998, HIV/AIDS was present in all 31 provinces and administrative regions of China, and government statistics indicated 60–70% of those infected were drug users. Other major modes of transmission included infected blood spread through blood donation clinics across the country and the sex trade. Before either of these routes of infection were identified, however, a handful of people contracted HIV after receiving transfusions of contaminated hemophilia blood products from the United States.

Through the early 1980s, multiple American pharmaceutical firms exported medical blood products contaminated with HIV to East Asia. Bayer Corporation exported plasma knowing the risks of HIV transmission, resulting in over one hundred infections in Taiwan and Hong Kong. Factorate, a Factor VIII product of Armour Pharmaceuticals Company, was imported to China and used in blood transfusions in 19 people in Zhejiang province between 1983 and 1985. Four of the recipients, all hemophiliacs, were infected with HIV, making them at the time the first identified cases of native Chinese infected within the country's borders. Armour had been aware that original sterilization methods for Factorate were inadequate since at least 1985.

The Chinese government reacted to the threat of HIV in the blood supply before any confirmed cases of infection had occurred. In September 1984, the Chinese Ministry of Health, in conjunction with the Ministry of Foreign Economic Relations and Trade (now the Ministry of Commerce) and the General Administration of Customs, issued a notice restricting imports on foreign blood products, including a complete ban on blood coagulation factors, specifically to prevent HIV/AIDS from entering the country. The bans were poorly enforced by some local governments, prompting central authorities in August 1985 to issue another notice nationwide, reiterating the ban and ordering all sub-national governments to comply. On 30 January 1986, all blood products, with the sole exception of human serum albumin, were banned from import into China for both organizational and personal use.

Epidemiology

Estimates from the Chinese Center for Disease Control and Prevention, World Health Organization, and UNAIDS calculated approximately 1.25 million people living with HIV/AIDS in China at the end of 2018, with 135,000 new infections over the previous year. It was by far the deadliest notifiable disease of 2018, killing 18,780 individuals, compared to 3,149 for tuberculosis, the second-most deadly. According to the People's Daily in 2018, the official newspaper of the Central Committee of the Chinese Communist Party, the government expects infections to continue to accelerate.

Data collection and reliability

Data on HIV/AIDS up through the early 2000s was very imprecise. Passive disease surveillance methods were established in 1986, with local clinics and medical providers reporting confirmed cases progressively through district, city, and provincial channels, and then ultimately to three separate national agencies under the Ministry of Health. The Chinese government did not begin active surveillance and systematic data collection until 1995, when 42 national surveillance sites were established in 23 provincial-level regions with the help of the World Health Organization. By 2006, China had achieved comprehensive HIV/AIDS surveillance nationwide, following expansion of the surveillance network to over 300 sites and reforms of the national reporting systems, although rural areas remained under-covered. By 2010, 1888 surveillance sites had been established.

Data from before the development of comprehensive surveillance suffered a number of shortcomings, including minimal coverage of the general population due to focus on high-risk groups, poor data on men who have sex with men (MSM), stovepiping among different government entities, and difficulties obtaining data from private healthcare providers. Through the early 2000s, the Chinese government limited discussion of data and statistics of HIV/AIDS in the country, and media only reported numbers approved by the government.

Accordingly, estimates from the period of the epidemic often were imprecise, tending to overestimate the overall number of cases. China did not begin to produce regular, systematic estimates of the prevalence of HIV/AIDS until 2003, doing so in conjunction with the United Nations, World Health Organization, and United States Centers for Disease Control. This initial estimate was tentatively 840,000 cases nationwide, but with a potential range of 430,000 to 1.5 million. This was revised down to 650,000 in 2005.

Other international estimates tended to greatly overstate the presence and potential growth of HIV in China before more reliable official data was available. For example, in 2002, a report by the United Nations Theme Group on HIV/AIDS in China, entitled "HIV/AIDS: China's Titanic Peril", had estimated up to 1.5 million infected cases, and warned of "[a] potential HIV/AIDS disaster of unimaginable proportion". A 2002 report by the US National Intelligence Council projected 10–15 million cases in China by 2010.

Current transmission

HIV in China is primarily transmitted through sexual contact, which accounts for over 90% of new infections. Sexual transmission gradually began to overtake the originally predominant routes of transmission, injection drug use and unsafe blood donation practices, throughout the 1990s and into the mid-2000s. In 2005, sexual transmission accounted for 50% of all new infections, and by 2007, a majority of HIV/AIDS cases overall were related to sexual transmission pathways.

Currently, major high-risk groups for HIV infection include intravenous drug users, men who have sex with men (MSM), and sex workers. The Chinese government has additionally established data collection and monitoring sites targeting male migrant workers, long-distance truck drivers, male STI clinic patients, antenatal care clinic patients, and college students.

MSM in particular have seen a significant increase in transmission rates since epidemiological studies examining them as a group began in 2000. MSM represented 26% of new reported cases in 2014, up from 2.5% in 2006. Increased migration from poorer regions with high HIV prevalence to urban areas and somewhat liberalized attitude towards homosexuality in China over the last two decades, resulting in more overall sexual activity, have been hypothesized as factors driving this trend.

MSM are also generally at a higher risk for contracting STIs, including syphilis, which may form a coinfection with HIV. Drug use contributes little to HIV infection among MSM, with the overwhelming majority of new cases being the result of sexual activity. More than one-fifth of MSM are married to women, which might speed the transmission of HIV to the general population, and outreach to this subgroup in particular can be difficult.

Mortality rates

The standardized mortality rate of HIV/AIDS rose from 0.33 per 100,000 people in 1990 to 2.50 per 100,000 in 2016, and the rate is higher in men than in women. Overall rates of mortality continue to grow as more individuals are infected. The provision of antiretroviral therapy (ART) among infected individuals, however, has greatly decreased mortality among patients receiving care since the early 2000s; by 2014 86.9% of eligible patients were receiving some form of ART.

Control and prevention

Overview of policy response

The response of the government of China to the HIV/AIDS crisis evolved in tandem with the epidemic itself. Generally, policy moved from preventive and containment measures aimed at keeping the disease from reaching the general population, often with a reliance on enforcement of public morality, to more active, data-driven control measures involving targeted education and harm reduction programs. Early law and policy implementation were often hindered by lack of knowledge among lawmakers on the severity and impact of HIV/AIDS and its potential for growth within China.

The first phase of Chinese HIV/AIDS policy ran from the first recorded in-country death in 1985, of a tourist in Beijing, until 1988/89, when the identified epidemic pattern expanded following the discovery of the outbreak in Yunnan. From 1985 to 1988, only 22 individuals tested positive for HIV in China, 18 of whom were foreigners or Overseas Chinese. HIV/AIDS was commonly viewed as a consequence of a Western lifestyle, and thus government efforts concentrated on protecting China from foreign transmission and promoting moral behavior and traditional values among citizens. "AIDS" was often punned in Chinese as "loving capitalism disease" (simplified Chinese: 爱资病; traditional Chinese: 愛資病; pinyin: Àizībìng), and public health authorities held that because homosexuality and other abnormal sexual behaviors were not prevalent in Chinese society, the disease had limited potential to spread.

In December 1985, the Ministry of Health submitted a report to the Secretariat of the Chinese Communist Party and the State Council, outlining the spread of the disease from Africa to Europe and America, emphasizing the predominantly sexual transmission routes, and listing measures the Ministry had taken to prevent its further spread into China. Laws and regulations attempting to eliminate the risk of foreigners infecting native Chinese were promulgated, under the assumption that this could keep the disease out of the country altogether.

By 1986, foreigners intending to stay over a year were required to undergo HIV testing, and HIV-positive people were legally barred from entering China. The New York Times reported that police in some cities were instructed to prevent foreigners from coming into sexual contact with Chinese people, including in discothèques, dance halls, and brothels. These early policies of containment, which also included wider crackdowns on drug use and prostitution, did little to check the spread of the disease, and possibly hindered initial identification of its domestic reservoirs.

International cooperation and funding

Prior to 2003, the majority of the capital for anti-HIV/AIDS policies and programs in China came from foreign sources, including NGOs like the Red Cross and Bill and Melinda Gates Foundation, foreign government agencies like the US Centers for Disease Control and Prevention, and international multilateral organizations like the UN and WHO. Dedicated funds for HIV/AIDS were first allocated by the Ministry of Finance in 1998. By 2015, 99% of HIV/AIDS response efforts were funded by domestic sources, and total expenditures reached nearly RMB 7 billion (approx. USD 1 billion) for the fiscal year 2017.

Discrimination against people with HIV/AIDS

Discrimination against HIV-positive individuals is an ongoing issue in China. Various provinces have historically adopted different measures related to people with HIV, most of which restrict their equal access to the public sphere. In some provinces in municipalities in the early 2000s, people with HIV were prohibited from holding certain jobs, HIV mothers could be required to undergo an abortion, and an HIV-positive couple could be legally barred from marriage on medical grounds.

The 2006 Regulation on the Prevention and Treatment of HIV/AIDS formally barred legal discrimination against anyone based on the HIV status. While lauding the Regulation as a major step forward, the United Nations Economic and Social Commission for Asia and the Pacific in 2015 reported that local governments often functionally ignored its provisions. A 2016 study in Guangzhou found that large numbers of healthcare providers also discriminated against HIV-positive patients, with over one-third refusing to treat such patients altogether.

In January 2013, China saw its first lawsuit awarding damages to a plaintiff on the grounds of HIV/AIDS discrimination. The plaintiff had been rejected for a job as a school teacher by the education bureau of Jinxian County, Jiangxi province specifically due to his HIV status.

Traditional Chinese medicine

As of December 2018, the only Traditional Chinese medicine therapy approved by the National Medical Products Administration (NMPA) of China was herbal ''tangcao'' tablets (Chinese: 唐草片; pinyin: Tángcǎo piàn). A number of other traditional supplements are under clinical trial reviews, but have not yet met NMPA standards. TCM research efforts are primarily focused on lessening the side effects of highly active antiretroviral therapy (HAART) and protecting against opportunistic infections.

Extracts of traditional medicines have served as bases for trials of antiviral therapies, including baicalin and Dantonic. A group of nine HIV/AIDS patients in 2017 were reported to have been functionally cured through TCM treatments, but these trials lacked controlled, regular observations. A 2018 study suggested substantive differences in protein expression and signaling in certain TCM-identified syndromes for those with HIV/AIDS. Controlled studies have yet to demonstrate any effect on long-term survival among HIV/AIDS patients, however, its validity is difficult to discern, and research is lacking on the interactions between Western and Traditional Chinese pharmacological products.

Activism

In China, like elsewhere, HIV/AIDS activists have played an important role in promoting public awareness and education about the disease, helping to prevent discrimination against people living with HIV/AIDS and highlighting factors which may impede efforts to check the spread of the disease. Compared to other social movements, the Chinese government has historically been more tolerant of HIV/AIDS-focused NGOs and civil society organizations, relying on them to reach out to marginalized groups most vulnerable to the disease.

The government at all administrative levels has also often sought to suppress or minimize activism perceived as sensitive, obscene, or a threat to stability, including that related to HIV/AIDS. This phenomenon was particularly pronounced in Henan, where the initial blood donation outbreak, in which local authorities were extensively involved, was most severe.

In 2007, activist Gao Yaojie was placed under house arrest in her home in Zhengzhou in order to prevent her from visiting the United States to receive an award from Vital Voices Global Partnership and meet with Hillary Clinton.

Socioeconomic effect

The process of the effect of HIV/AIDS can be described as having three key stages: first, the effect experienced at the micro level; second, at the sectoral level; and finally, at the macro level. The effect began to be observed in China at the micro, or household level, and will most certainly be observed in the future at the sectoral level. Individuals and families have been bearing both the economic and social costs of the disease, and the poverty of those affected have increased and will further increase substantially.

Expenditures for the health sector will increase, for both treatment and prevention interventions. The macro level has been mostly unaffected. But if without effective preventive action, the HIV spread in the general population at large will affect the macro level as have happened in some countries in sub-Saharan Africa.

Media

Documentaries

Chinese-American director Ruby Yang has made a documentary about AIDS in rural China, which premiered on 14 June 2006, entitled The Blood of Yingzhou District.

An abridged version of Robert Bilheimer's acclaimed US-made 2003 documentary A Closer Walk was shown on China Central Television (CCTV) on World AIDS Day, 1 December (Friday), 2006, and was rerun Sunday and Monday. It was viewed by around 400 million people. The 75-minute-long documentary, narrated by actors Will Smith and Glenn Close, had premiered in the United States in 2003.