- HIV/AIDS in the People's Republic of China
The HIV/AIDS pandemic scene in
East Asiais largely dominated by China. Much of the current spread of the human immunodeficiency virus(HIV) in China has been through intravenous drug use and prostitution. In China, the number of affected by HIV has been estimated at between 430,000 and 1.5 million, [Steinbrook R. [http://content.nejm.org/cgi/content/full/351/2/115 The AIDS Epidemic in 2004] . "N Engl J Med" 2004 (July 8); 351(2): 115-117.] with some estimates going much higher.National Intelligence Council. [http://www.fas.org/irp/nic/hiv-aids.html The next wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, China] . ICA 2002-04 D. September, 2002.] American Enterprise Institute, Washington, D.C. [http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=722 Can Asia avoid the AIDS typhoon?] Nov 11, 2002.] In many rural areas of China during the mid-1990s, particularly in the province of Henan, tens to hundreds of thousands of farmers and peasants were infected with HIV through participation in state-run, contaminated blood collectionprograms.
China is not yet near to what many would consider, a widespread
AIDS epidemic, but the infectionrate (incidence) has been rising sharply and the potential impact of a serious outbreak in a country as large as China would be disastrous for both its own and the world's economy. The underlying government response to HIV/AIDS is now that of preemptive intervention.
Chronology of major HIV/AIDS developments in China
*In 1984, Zeng Yi, an academician with the
Chinese Academy of Sciences, starts HIV serum testing and confirms that the virus has entered the Chinese mainlandin 1982 and infected the first Chinese in 1983.
*In June 1985, China records its first death of an AIDS patient.
*In September 1985, China bans importation of blood products.
*In 1986, four Chinese
hemophiliapatients are found HIV positive after blood transfusions. The blood products were imported.
*In 1987, a 13-year-old Chinese hemophiliac, who was infected with HIV after transfusion of foreign blood products, dies of AIDS.
*In December 1989, China records its first HIV outbreak in drug users.
*In 1990, the Ministry of Health sets up the National AIDS Committee.
*In 1992, the National Health Education Institute sets up the country's first HIV/AIDS
*In 1992, the government confirms that it has recorded 11 AIDS patients and announces a medium-term plan on the prevention and control of HIV/AIDS.
*In January 1995, China records its first HIV outbreak in plasma donors.
*Also in January 1995, China sets up its HIV/AIDS sentinel surveillance system.
*In May 1995, China shuts down all blood/plasma collection stations.
*In September 1996, China launches its first condom trials.
*In November 1997, China begins its first workshop on effective intervention strategies.
*In July 1998, HIV is found in all 31 Chinese provinces for the first time.
*In 1998, China's first 'Law on Blood Donation' takes effect on October 1. The law requires health authorities to standardize
blood collection. Illegal blood collection for commercial purposes is banned.
*In 1998, on November 30, the government issues a 13-year plan (1998-2010) on the prevention and control of HIV/AIDS, which sets a target to keep the HIV positive population below 1.5 million, called "Medium-long Term Plan on Prevention and Control of HIV/AIDS (1998-2010)".
*In 1999, the Ministry of Health issues an administrative guideline, emphasizing the protection of the legitimate rights of people infected with HIV.
*In October 1999, China runs its first needle-exchange program (NEP) trials.
*In June 2001, the government issues its "Action Plan on HIV/AIDS Prevention and Containment (2001-2005)".
*In August 2002, for the first time, an official of the government of China acknowledges that the country is facing an AIDS epidemic and discloses that HIV infections in China rose 67.4% in the first six months of 2001 compared with the first six months of 2000.
*In December 2002, China conducts its first antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) trials.
*In 2003, in September, Vice Health Minister
Gao Qiangpledges a set of anti-HIV measures at the 58th UN Assembly's special session of AIDS. The measures mean a larger range of government responsibility on AIDS prevention and control, including free HIV treatment for poor sufferers, establishment of AIDS control centers, the legislation of AIDS-related laws and international cooperation.
*In 2003, Premier
Wen Jiabaovisits AIDS patients in a Beijinghospital and becomes the first premier of China to publicly shake hands with AIDS patients in a bid to eliminate social discrimination.
*In December 2003, China initiates its ‘Four Free and One Care’ policy: free ARV drugs, free prevention of mother-to-child transmission, free voluntary counselling and testing, free schooling for children orphaned by AIDS, and care to people living with HIV/AIDS. It has since expanded to more than 120 sites nationwide.
*In 2003, the Ministry of Health and the
United Nations Theme Group on HIV/AIDSin China jointly issue an assessment report on December 1, which estimates that China has 840,000 HIV positive people, of whom 80,000 have full blown AIDS. The assessment says that despite the overall low prevalence rate (an adult infection rate of less than 0.1 percent), the epidemic has spread to 31 provinces. In China the government estimated that up to 850,000 people had contracted HIV by 2000 — more than half of them having acquired the virus since 1997.
*In February 2004, the State Council AIDS Working Committee is established.
*In March 2004, methadone maintenance treatment (MMT) trials begin.
*In 2004, Vice Premier
Wu Yiopenly advocates behavior intervention to the high risk population at a national working meeting on HIV/AIDS in April, marking an unprecedented step forward in the fight against the disease.
*In 2004, on November 30, President
Hu Jintaovisits AIDS patients in Beijing for face-to-face talks.
*In 2006, the Ministry of Health,
UNAIDSand the World Health Organizationjointly issue an assessment in January in Beijing, lowering the estimated number of HIV/AIDS cases in China to 650,000, nearly 200,000 less than the 2003 estimate. The assessment also estimates that China has 75,000 AIDS patients.
*In 2006, new regulations and a second 5-year plan issued by the State Council on the prevention and control of HIV/AIDS took effect on March 1.
At the start of the 21st century many Western countries were battling the reluctance of the Vatican, some
Muslimnations, and other countries such as China to single out homosexuals, prostitutes, and drug users for special attention out of fear of appearing to condone their lifestyles. [Sethna HN. [http://www.case.edu/med/epidbio/mphp439/NGOs&AIDS.htm The role of non-governmental organisations (NGOs) in HIV/AIDS prevention and care.] MPHP 439, Department of Public Health. Case Western Reserve University, Cleveland, OH 44106. Spring 2003.]
Early control strategies
Initially, the Chinese government focused its preventive strategies on stopping HIV from entering the country. Regulations were introduced that required foreigners who intended to stay 1 year or more and Chinese residents returning from overseas to have an
HIV test. [Standing Committee of the National People's Congress. Law on the control of the entry and exit of aliens. Order number 31 of the President of the People's Republic of China. Beijing, 1985 (in Chinese).] [Standing Committee of the National People's Congress. Law on the control of the exit and entry of Chinese citizens. Order number 32 of the President of the People's Republic of China. Beijing, 1985 (in Chinese).] Standing Committee of the National People's Congress. Frontier health and quarantine law. Order number 46 of the President of the People's Republic of China. Beijing, 1987 (in Chinese).] All imported blood products were banned. [Ministry of Health of the People's Republic of China. Notice on banning import of blood products such as factor VIII. State Council Document (1985) number 49. Beijing, 1986 (in Chinese).] [Ministry of Health of the People's Republic of China. Notice on strengthening management of imported blood products. State Council Document (1986) number 2. Beijing, 1987 (in Chinese).] There were attempts to stop transmission within the country as well – e.g., laws against drug useStanding Committee of the National People's Congress. Decision on the prohibition of narcotic drugs. Beijing, 1990 (in Chinese).] and prostitutionStanding Committee of the National People's Congress. Decision on the strict prohibition against prostitution and whoring. Beijing, 1991 (in Chinese).] were strengthened and authorities were allowed to isolate HIV-positive individuals. The hazards related to uncontrolled illegal collection of blood and plasma were realised in 1994 after an outbreak in blood donors, and countermeasures were initiated. In much the same way as other countries, traditional public healthmethods of containment and isolation of infectious diseasecases proved ineffective. [Wu Z, Rou K, Cui H. The HIV/AIDS epidemic in China: history, current strategies and future challenges. "AIDS Educ Prev" 2004; 16 (3 suppl A): 7-17.] Containment policies occurred in the context of rapid social and economic change, in which there were increases in drug use and changing sexual mixing patterns. These early policies did little to stop transmission of HIV; in fact, they probably promoted concealment of risk activities and made identification of HIV reservoirs more difficult. [Li D, Xia G, Qiu R, Hamblin J, Yue T. Law, policies and regulations concerning HIV/AIDS prevention and containment: an assessment and recommendations. Beijing: United Nations Development Programme, 2003.] Xue B. HIV/AIDS policy and policy evolution in China. "Int J STD AIDS" 2005; 16: 459-464.] Husain L. Policing AIDS in China: official discourses, change, continuity, and unofficial voices. In: Christiansen F, Dosch J, Caroline R, Hamelman S, eds. Leeds East Asia Papers. Leeds: Department of East Asia Studies, University of Leeds, 2004.]
Development of HIV/AIDS policy
Information and communication networks
The attitudes of government officials shifted substantially over time, a result of increasing
scientific evidencethat Chinese peoplewere becoming infected, the dramatic devastation caused by HIV/AIDS in other countries, and research in China that showed that HIV transmission could be reduced with targeted interventions.
As early as the mid-1990s, Chinese officials began to organize study tours to learn from the successes and failures of other countries in combating HIV/AIDS and to bring back information about strategies for HIV/AIDS control that could be adapted for China. Tour groups including officials from the Ministries of Health, Public Security, Justice, Education and Finance, Commissions of Development and Reform, and Population and Family Planning, as well as law and policymakers from the State Council, visited many places, including
Australia, the USA, Brazil, Thailand, Europe, and Africa. These tours provided an opportunity for officials to learn from their counterparts in other countries, as well as promoting relationships between the different Chinese government sectors that participated in the study tours.
Workshops that involved key government agencies were also held within China to further foster cross-sector communications. The organization of Chinese government services is traditionally hierarchical and departmentalized, not directly cultivating cooperation and collaboration across sectors. This tradition made the organization of multifaceted responses appropriate for HIV/AIDS control difficult. The WHO Global Programme on AIDS, and subsequently UNAIDS, together with other
UN agenciesin Asia and the Pacific, such as the UN Drugs Control Programme (now the UN Office of Drugs and Crime), had important roles in working with the government of China to organize and facilitate cross-sector discussions.
One workshop in particular was pivotal in pushing policies to support interventions that targeted high-risk groups in China. Held in 1997 and organized by the Chinese Academy of Preventive Medicine (renamed the Chinese Center for Disease Control and Prevention [CDC] in 2002) and the
University of Californiaat Los Angeles, the workshop drew together scholars from sociology, ethics, public health, and education, as well as government officials and representatives of international agencies such as WHO, UN, and the World Bank. This workshop was the first open discussion of evidence-basedbut controversial intervention strategies that targeted those at high risk of HIV infection who were also highly stigmatized - e.g., sex workers, IDUs, and men who have sex with men. Although controversial - pitting scientific, evidence-based prevention approaches against conservative, moralistic attitudes - the consensus acknowledged the possible benefit of the implementation of new prevention strategies.
Members of these various workshops and study tours have been responsible for the identification of effective strategies that have increasingly been at the forefront of HIV control policy in China. They have also contributed to the development of strategic documents, including the "Medium- and Long-Term Strategic Plan for HIV/AIDS (1998–2010)",Ministry of Health, State Development Planning Commission, Ministry of Science and Technology, Ministry of Finance. Chinese national medium-and long-term strategic plan for HIV/AIDS (1998–2010). State Council Document (1998) number 38. Beijing, 1998 (in Chinese).] the "Action Plan on HIV/AIDS Prevention and Containment (2001–2005)",State Council of the People's Republic of China. China's action plan on HIV/AIDS prevention and containment (2001–2005). State Council Document (2001) number 40. Beijing, 2001 (in Chinese).] and the "AIDS Regulations". Other key documents warned of the potential epidemic in China and might have influenced the attitudes of policymakers. "China's Titanic Peril", [The UN Theme Group on HIV/AIDS in the People's Republic of China. China's titanic peril: 2001 update of the AIDS situation and needs assessment report. Beijing: UNAIDS, 2002.] published by the UN in 2002, made the unsubstantiated prediction that China could have 10 million HIV-infected individuals by 2010, a figure that has been repeatedly misused in discussions of China's HIV future. A Joint Assessment of HIV/AIDS Prevention, Treatment and Care in China (2004), developed jointly by UNAIDS and the State Council of China, estimated that China had 840,000 people living with HIV/AIDS. This figure has been revised down to 650,000 in 2005 in light of more representative
data collectionand more appropriate estimationmethods. Although this figure represented a prevalence of about 0.05%, it was substantially higher than previous government estimates (300,000 in 1998) and provided the impetus for immediate scale-up of prevention and control strategies.
cientific evidence for innovative policies
Concurrent with educational activities and network building for government officials, Chinese researchers identified the key risk groups, documented and predicted the course of the epidemic, observed successful programs in other countries, and tested the effectiveness of behavioral interventions. HIV-related research projects were done by universities, hospitals, and community agencies, both independently and as collaborative projects with other domestic and international institutions. Most research and surveillance commissioned by the Chinese government was and is done by the National Center for AIDS/STD Control and Prevention (NCAIDS) at the . At the local level, almost all HIV research and intervention - whether done by the Chinese CDC or other research organizations - is done in collaboration with provincial and county CDCs, township hospitals, and village health workers. Research initiated by the Chinese CDC administrators, especially that commissioned by the Ministry of Health, is diffused and implemented faster than research done outside the existing government structure.
Changes in government
In 2003, a new administration led by President
Hu Jintao, Premier Wen Jiabao, and Vice Premier and Health Minister Wu Yisubstantially accelerated the commitment to and implementation of evidence-based HIV policies. Under this administration, a number of initiatives have been introduced: the China Comprehensive AIDS Response (China CARES), which assists 127 high-prevalence counties in providing care and support to people living with HIV/AIDS; the “Four Free and One Care” policy (see panel); and the formation of a State Council AIDS Working Committee responsible for the development of a comprehensive policy framework (e.g., the Notice on Strengthening HIV/AIDS Prevention and Control). New policies, supported by expanded budgets, have been introduced, which has permitted a substantial acceleration in programme development, testing, and scale-up.
In March 2006, the
State Council of the People's Republic of Chinaofficially announced the first legislation directly aimed at controlling HIV/AIDS: the AIDS Prevention and Control Regulations.State Council of the People's Republic of China. Regulations on AIDS prevention and treatment. Decree of the State Council of the People's Republic of China number 457. Beijing, 2006 (in Chinese).] These regulations, together with the Five-Year Action Plan to Control HIV/AIDS (2006–2010),State Council of People's Republic of China. China's action plan for reducing and preventing the spread of HIV/AIDS (2006–2010). State Council Document (2006) number 13. Beijing, 2006 (in Chinese).] are an important step in the development of government policy related to the care and prevention of HIV/AIDS. Although considered bold, these regulations were passed more than 20 years after the first case of HIV infection was identified. The development of a coherent policy was the result of a long and unsystematic process that involved initial missteps, considerable domestic and international education, debate, iterative trial-and-error learning, and scientific studies. The new legislation resulted from communication and coordination among many agencies, including administrators, service providers, politicians, the scientific community, and policymakers.
The Chinese government has been widely criticized for its failure to respond to the HIV/AIDS threat and for systematic suppression of information about the size of the problem. [Asia Division, Human Rights Watch. Locked doors: the human rights of people living with HIV/AIDS in the People's Republic of China. "Human Rights Watch" 2003; 15: 1-95.] [Ruger JP. Democracy and health. "Q J Med" 2005; 98: 299-304.]
Current numbers affected
The Ministry of Health has said there are 650,000 HIV/AIDS cases, half of them among intravenous drug users, out of a nation of 1.3 billion people. [Ministry of Health, People's Republic of China, Joint United Nations Programme on HIV/AIDS, World Health Organization. [http://data.unaids.org/publications/External-Documents/RP_2005ChinaEstimation_25Jan06_en.pdf Update on the HIV/AIDS epidemic and response in China] . 2006.] (Although this overall estimate of HIV and AIDS cases was lowered in January 2006 – in a report put together by the Chinese government, the
World Health Organisationand the Joint United Nations Programme on HIV/AIDS(UNAIDS) – from 840,000 to 650,000, officials say this reflected the use of different statistical methodology rather than a drop in the incidence.) Epidemiology experts have said that 1.5 million is closer to the true figure.
According to China's health ministry, there are now 183,733 registered cases of HIV/AIDS in 2006, a rise of nearly 30 percent over 2005. But the real figures are likely to be much higher as testing and surveillance techniques are limited, especially in the countryside, and entrenched discrimination may have discouraged many from reporting.
Out of the 840,000 HIV carriers in the mainland, the health ministry estimates in early 2004 that there are 80,000 suffering from AIDS. HIV cases have been reported in all the Chinese mainland's 31 provinces, autonomous regions and municipalities. [Xinhuanet: [http://news.xinhuanet.com/english/2005-03/30/content_2765639.htm China to gather AIDS information on-line] . March 30, 2005.]
Beginnings of the epidemic
China's first AIDS case was identified in 1985 in a dying tourist. [Settle E. AIDS in China: an annotated chronology: 1985–2003. Montreal: China AIDS Survey, 2003.] In 1989, the first indigenous cases were reported as an outbreak in 146 infected
heroinusers in Yunnanprovince, near China's southwest border. [Ma Y, Li ZZ, Zhang KX. Identification of HIV infection among drug users in China. "Zhonghua Liu Xing Bing Xue Za Zhi" 1990; 11: 184-185 (in Chinese).] Between 1989 and the mid-1990s, HIV spread steadily from Yunnan into neighboring areas and along the major drug traffickingroutes, then from injecting drug users (IDUs) to their sexual partners and children. In the mid-1990s, the occurrence of a second major outbreak in commercial plasma donors in the east-central provinces became apparent. [Wu Z, Liu Z, Detels R. HIV-1 infection in commercial plasma donors in China. "Lancet" 1995; 346: 61-62.] Plasma donors were paid to donate blood, the plasma removed, then the red blood cells reinfused to prevent anaemia. Reuse of tubing and mixing during collection and reinfusion led to thousands of new infections.Wu Z, Rou K, Detels R. Prevalence of HIV infection among former commercial plasma donors in rural eastern China. "Health Policy Plan" 2001; 16: 41-46.] [Zhuang K, Gui X, Su B, Tien P, Chen Z, Zhang L. High prevalence of HIV infection among women and their children in Henan Province, China. "J Acquir Immune Defic Syndr" 2003; 33: 649-650.] At the same time, HIV was also spreading through sexual transmission. By 1998, HIV had reached all 31 provinces and was in a phase of exponential growth,State Council AIDS Working Committee Office, UN Theme Group on HIV/AIDS in the People's Republic of China. A joint assessment of HIV/AIDS prevention, treatment and care in China. Beijing: China Ministry of Health, 2004.] which, by 2005, had culminated in an estimated 650,000 infections.Ministry of Health of China, UNAIDS, WHO. 2005 update on the HIV/AIDS epidemic and response in China. Beijing: Ministry of Health, 2006.]
The potential risks are very high. The most recent data showed that the number of new cases in China rose by 70,000 in 2005, which led to some health officials to raise concerns that infections were moving from high-risk groups into the broader population. The ministry attributes 37% of the new cases to drug use and 28% to unprotected sex.
Health officials are also mindful of the experience in Africa in the 1990s - for instance, the quick rise in
South Africa's incidence from 1 percent at the start of the decade to about 20 percent in 2003 – which underlines the strong case for an early and aggressive policy response.
An increase in diagnoses might mean that HIV testing has become more easily available than in preceding years, or that the stigma associated with HIV has declined, encouraging more to get tested.
The subtypes of
HIV-1found in China include B, Thai B, A, C, D, E, F, G, and BC and BB recombinants. However, the epidemiological distribution and relative importance of these subtypes need further study.
China's HIV/AIDS epidemic can be divided into three phases.
*The first phase, in 1985-8, involved a small number of imported cases in coastal cities — mostly foreigners and
overseas Chinese. Four people with haemophilia from Zhejiangprovince also got infected with HIV after using imported factor VIII.
*The second phase, from 1989 to 1993, began with finding HIV infection in 146 drug users among minority communities in Yunnan province in the southwest, adjacent to the “Golden Triangle” bordering Myanmar, Laos, and Vietnam.
*The third phase began in 1994, when a number of infections were reported among drug users and commercial plasma donors. In the 1990s, HIV gained a foothold in China largely due to tainted blood transfusions in hospitals and schemes to buy blood plasma, where it was collected using unsanitary means. Although the government today acknowledges responsibility in the transfusion cases, many victims still have trouble receiving compensation. By 1998 HIV infection had been reported from all 31 provinces, autonomous regions, and municipalities under control of the central government. Though drug users accounted for 60%-70% of reported HIV infections, the number of infections through heterosexual transmission had increased steadily to 7%.
High risk groups
*Sex workers/prostitutes (see: "
Prostitution in the People's Republic of China"); Chinese authorities estimate there are 3 million to 4 million women working as prostitutes in so-called karaoke bars, hair salons, massage parlors and truck stops.
*Homosexual/bisexual men (see: "
Homosexuality in China")
*Intravenous drug users
*Migrant workers (the "floating population"), are invariably single, poorly paid and from less progressive regions of China where sex education remains taboo, are immediately exposed to the high-risk groups. Workers travel between work and home for the periodic visit with spouses — the virus is virtually guaranteed to affect a broad geographic range.
Predictions of the size of the HIV/AIDS epidemic in China have been substantially overestimated by several expert bodies. Notable examples include:
*In 2002, a UN-commissioned report, emotively entitled "China's Titanic peril", [Eldis gateway. [http://www.eldis.org/static/DOC9892.htm HIV/AIDS: China's Titanic peril: 2001 update of the AIDS situation and needs assessment report] . UNAIDS, 2002.] estimated that China had about 1 million cases of HIV, and that it was on the brink of an "explosive HIV/AIDS epidemic... with an imminent risk to widespread dissemination to the general population". The report continued: "a potential HIV/AIDS disaster of unimaginable proportion now lies in wait."
*In September 2002, the US
National Intelligence Councilestimated that 1-2 million people were living with HIV in China, and predicted 10-15 million cases by 2010. The National Intelligence Council claimed that these figures were more reliable than previous estimates because they did not rely on official Chinese sources, which the National Intelligence Council asserted "systematically understate the actual figures", but rather incorporated assessments by academics and non-governmental organizations working in the field.
*In November 2002, the
American Enterprise Institutereferred to the situation as the "AIDS typhoon". This report emphasized the probable damage to the economy because HIV would spread among young educated urban people.
*In April 2004, HIV/AIDS was referred to as China's timebomb by the
Center for Strategic and International Studies(Washington, DC, USA). [Gill B, Morrison SJ, Thompson D, eds. [http://www.csis.org/media/csis/pubs/040413_china_aids.pdf Defusing China's timebomb - sustaining the momentum of China's HIV/AIDS response] . A report of the CSIS HIV/AIDS delegation to China, April 13-18, 2004.]
*The number of people infected with HIV/AIDS in the People's Republic of China "could rise to 10 million in the next six years unless the government acts urgently and effectively to prevent an epidemic", the
Joint United Nations Programme on HIV/AIDSsaid in its 2004 biennial report on the global AIDS epidemic. The virus has spread to all provinces of China but with no distinct pattern of infection, and there are “extremely serious” epidemics in parts of the country despite a low rate of the disease nationwide of about 0.1 percent, the report said.
These estimates assumed substantial spread of the virus from high-risk groups to the general population, yet the few population studies, and, in particular, trends from sentinel surveillance of pregnant women in high-risk areas show that such spread has not occurred. [Hesketh T, Huang XM, Wang ZB, Xing ZW, Cubitt DW, Tomkins AM. Using the premarital examination for population-based surveillance for HIV in China. "AIDS" 2003; 17: 1574-76.] [Qu S, Sun X, Zheng X, Shen J. [http://gateway.nlm.nih.gov/MeetingAbstracts/102250025.html National sentinel surveillance of HIV infection in China from 1995 to 2001] . XIV International AIDS Conference, Barcelona, Spain, July 7-12, 2002: WePeC6072 (abstr).] [Hong L, Mo LH, Liu H. Prevention of HIV transmission from mother-to-child in Yunnan. "Mod Prev Med" 2001; 28: 68-69.] Therefore, these predictions were made on unfounded assumptions. The inaccurate predictions showed how even well-respected groups willingly accept and repeat a number (especially one that is high and sensationalist) irrespective of the assumptions of the underlying calculations, starting a cycle when repeated often enough. Some have argued that the effect of these high and inaccurate predictions have drawn attention and resources away from areas of greater need. For example, China's burden of disease from
tobacco useis enormous. [Wang L, Kong L, Wu F, Bai Y, Burton R. Preventing chronic diseases in China. "Lancet" 2005; 366:1821-24.]
HIV/AIDS surveillance system
The national surveillance system in China has three components:
*(1) National disease reporting programme for 35 notifiable communicable diseases that covers the entire population.
*(2) 845 national disease surveillance points covering 1% of China's population in 31 provinces, regions, and municipalities.
*(3) Several disease specific surveillance systems including one for HIV infection and AIDS.
Additionally, 42 national HIV/AIDS sentinel surveillance points have been established in 23 provinces since 1995.
The first step in understanding the extent of an epidemic was to be able to identify cases. National sentinel surveillance has been implemented since 1995, but was initially restricted to high-risk areas and to attendees at sexually transmitted disease clinics, female sex workers, drug users, and long-distance truck drivers. Surveillance has gradually been expanded to 845 national sites and now also includes pregnant women and men who have sex with men.
Around the same time, voluntary testing and counseling was made available in some communities, but, even where available, was rarely used. Reluctance to seek
HIV testing was probably due to a number of causes - e.g., cost, inaccessibility of services, absence of any treatment, scant publicity or advocacy for testing, low or no perceived risk, and stigma associated with the use of testing services.UNAIDS. [http://siteresources.worldbank.org/INTEAPREGTOPHIVAIDS/Resources/fs_stigma_discrimination_en_pdf.pdf Stigma and discrimination fact sheet] ] [Herek GM. AIDS and stigma. "Am Behav Sci" 1999; 42: 1102-1112.] Choi KH, Lui H, Guo Y, Han L, Mandel JS. Lack of HIV testing and awareness of HIV infection among men who have sex with men, Beijing, China. "AIDS Educ Prev" 2006; 18: 33-43.] [Wu Z, Rou K, Xu C, Lou W, Detels R. Acceptability of HIV/AIDS counseling and testing among premarital couples in China. "AIDS Educ Prev" 2005; 17: 12-21.] Since 2004, the government has addressed the environmental barriers. The high cost was addressed in 2003 by making free HIV testing available for the poor, [Koralage N. China to offer free HIV testing and treatment. "BMJ" 2004; 328: 975.] and later, under the 'Four Free and One Care' policy, antiretroviral therapywas made freely available for all through the Chinese health system. The number of screening laboratories has been expanded to 5500, and there are now 99 laboratories able to do confirmatory HIV tests. Free HIV testing has been made available, and expanded from 365 counties in 15 provinces in 2002 to over 2300 counties, with 3037 sites, in all provinces in 2006. The AIDS Regulations have introduced penalties for health units that do not provide free testing on request.
The rapid expansion of testing infrastructure has been largely prompted by the introduction of provider-initiated routine testing campaigns to identify infected individuals and put them in contact with treatment services. Client-initiated testing was failing to identify most infected individuals, so campaigns to screen high-risk groups, including drug users, commercial sex workers, prisoners, and former plasma donors, were commissioned to link patients to treatment services. [Wu Z, Sun X, Sullivan SG, Detels R. Public health. HIV testing in China. "Science" 2006; 312: 1475-1476.] The campaigns have resulted in a substantial increase in the number of individuals who know their
HIV status, with an additional 60,000 people living with HIV/AIDS identified. This increased identification explains, at least in part, the rapid rise in reported HIV cases in the early 21st century. However, even with this effort, only about 22% of the estimated 650,000 HIV-infected individuals living in China at the end of 2005 have been identified. Routine testing in high-risk groups continues.
Control and prevention
Early efforts to control the HIV/AIDS epidemic emphasized enforcement of laws against high-risk behavior, but later lessons from effective interventions in pilot programs and in other countries (e.g. needle exchange programs in Australia and condom campaigns for sex workers in Thailand) have led to a more evidence-based approach. [Wu ZY, Sullivan S, Wang Y, Rotheram MJ, Detels R. Evolution of China's response to HIV/AIDS. "Lancet" 2007; 369: 679-90.]
The process of
policydevelopment have not been tidy because of tensions arising particularly from those between public health officials and the police and those within public security over the management of illegal drug use and prostitution. However, the recently announced AIDS Prevention and Control Regulations [ [http://www.china-aids.org/english/aidsreg-2006-intro China AIDS Info] .] are an example of evidence-based policy, even if their implementation is highly variable across China.
In 2003, in response to the ever growing spread of HIV/AIDS, the Chinese government declared a strong commitment to its prevention. Long and medium term plans for controlling and preventing HIV/AIDS have been developed, and a central government coordinating committee has been formed among 33 ministries.
Four main factors have driven China's response to the
HIV/AIDS pandemic: (1) existing governmentstructures and networks of relationships; (2) increasing scientific information; (3) external influences that underscored the potential consequences of an HIV/AIDS pandemic and thus accelerated strategic planning; and (4) increasing political commitment at the highest levels. China's response culminated in legislationto control HIV/AIDS — the AIDS Prevention and Control Regulations.
Three major initiatives are being scaled up concurrently. First, the government has prioritized interventions to control the epidemic in injection drug users,
sex workers, men who have sex with men, and plasma donors. Second, routine HIV testing is being implemented in populations at high risk of infection. Third, the government is providing treatment for infected individuals. These bold programs have emerged from a process of gradual and prolonged dialogue and collaboration between officials at every level of government, researchers, service providers, policymakers, and politicians, and have led to decisive action.
Current treatment plan
The government now provides free AIDS drugs to rural residents and city-dwellers without insurance. Other measures include:
*Free drugs to HIV-infected
pregnant womento prevent mother-to-child transmission, and HIV testing of newborn babies.
schoolingfor AIDS orphans.
*Care and economic assistance to the
households of people living with HIV/AIDS.
Antiretroviral treatment for people with HIV/AIDS
In 2001 and 2002, the number of patients living with HIV/AIDS being identified through treatment services began to increase. As many as 69,000 of these people were the rural poor who had been infected when they sold their blood and plasma in the mid-1990s and who were unable to access or afford much-needed
antiretroviral treatment. On the basis of the successes of programmes in other nations, such as Brazil, [Teixeira PR, Vitoria MA, Barcarolo J. Antiretroviral treatment in resource-poor settings: the Brazilian experience. "AIDS" 2004; 18 (suppl 3): S5-S7.] a free antiretroviral therapy programme was piloted in late 2002 in Shangcai county, Henan province, one of the most severely affected areas.Zhang FJ, Pan J, Yu L, Wen Y, Zhao Y. Current progress of China's free ART program. "Cell Res" 2005; 15: 877-882.] Patients were provided with a combination of zidovudineor didanosineplus lamivudineand nevirapine. On the basis of the improved health status and survival of the initial cohort, the programme was scaled up in early 2003, mainly through the China CARES programme.
The provision of free antiretroviral therapy to rural residents and the urban poor became policy in 2003 under the 'Four Free and One Care' policy. The National HIV/AIDS Clinical Taskforce took the lead in establishing the programme, and set up a
databaseto monitor it. As of the end of 2006, more than 30,640 patients have been treated in 800 counties in all 31 provinces. Research to inform further expansion and improvement of the programme is ongoing. Initial reports indicate that the current treatment regimen has a high drop-out rate (at least 8%), mainly due to side-effects, drug resistance, difficulty with adherence, and progression of disease. Therefore, the government is currently exploring options within the pharmaceutical industryto make additional regimens available, which will address both the issues of compliance, by making regimens with fewer side-effects available, and resistance, by making available additional lines of treatment.
The government has recently approved a series of pilot programs, such as:
needle exchangeprogram for drug users who have gone through detoxification
methadonemaintenance treatment program
*vending machines selling
condomshave been set up in public places.
Reduction of transmission via injecting drug use
Intravenous drug use represents the largest single cause of HIV transmission in China, accounting for 44.3% of infections at the end of 2005. Ministry of Public Security data suggests that the number of registered drug users has risen steadily at a rate of about 122% per year, from 70,000 in 1990 to 1.16 million in 2005. The total number, including unregistered drug users, is thought to be much higher, with one estimate placing the figure at 3.5 million; [Kulsudjarit K. Drug problem in southeast and southwest Asia. "Ann N Y Acad Sci" 2004; 1025: 446-457.] the UNODC World Drug Report estimated that in 2003, 0.2% of 16–64-year-olds (i.e., 1.7 million people) were
opiateabusers. [UNODC. 2006 World drug report. Geneva: United Nations Office on Drugs and Crime, 2006.] The most commonly used drug is heroin, which accounts for 85% of total reported drug use, although amphetaminesare becoming more common, especially in urban areas. [National Drug Abuse Surveillance Center. Annual report on drug surveillance 2001. Beijing: NDSAC in National Institute on Drug Dependence, China, 2001.] Many drug users begin heroin use by smoking, but later find it more cost effective to inject because of the stronger effect gained from injecting a smaller amount. Sharing injection equipment is common.Yap L, Wu Z, Liu W, Ming ZQ, Liang S. A rapid assessment and its implications for a needle social marketing intervention among injecting drug users in China. "Int J Drug Policy" 2002; 13: 57-68.]
National policymakers have recently shifted their position and publicly acknowledged the extent and pattern of increasing drug use, which has led to a rapid increase in treatment options for drug users. According to the regulations on the prohibition of
narcotics, drug users identified by authorities for the first time are fined or sent to a voluntary detoxificationcenter run by the health system, which might include short-term use of methadone, buprenorphine, or traditional Chinese medicine. Detoxification costs 2000–5000 yuan (about US$250–625) for one phase of treatment. [Zhao C, Liu Z, Zhao D, et al. Drug abuse in China. "Ann N Y Acad Sci" 2004; 1025: 439-445.] Qian HZ, Schumacher JE, Chen HT, Ruan YH. Injection drug use and HIV/AIDS in the People's Republic of China: review of current situation, prevention and policy implications. "Harm Reduct J" 2006; 3: 4.] If, as often happens, the treatment is not successful, relapsing patients identified by authorities are sent to a compulsory rehabilitation center, administered by the Ministry of Public Security, for 3–6 months. Those with multiple relapses are detained in a re-education-through-labor center, managed by the Ministry of Justice, for 1–3 years. In reality, internment procedures and durations vary enormously between administrative units. In general, centers focus on detoxification. Although some health educationor treatment is provided, the relapserate is extremely high. [Humeniuk R, Ali R. The first methadone clinic in Beijing. "Drug Alcohol Rev" 2005; 24: 285-287.] [Liu H, Grusky O, Li X, Ma E. Drug users: a potentially important bridge population in the transmission of sexually transmitted diseases, including AIDS, in China. "Sex Transm Dis" 2006; 33: 111-117.] [Zou K. The “Re-education Through Labour” system in China's legal reform. "Criminal Law Forum" 2002; 12: 459-485.]
Cooperative actions by politicians, policymakers, government officials, and scientific researchers have resulted in the introduction of new strategies for
drug controlover the past 6 years. For example, the government is working with neighboring countries to prevent drug smuggling, and is increasing anti-drug education for the general population and in schools. The government has also commissioned research on harm reductionstrategies, such as methadone maintenance treatmentand needle exchange programmes.
Needle exchange programmes
Needle exchange programmes are not a strategy officially sanctioned by the Ministry of Public Security since such strategies give the appearance of condoning drug use. Thus, when this strategy was first introduced, it was called needle social marketing - increasing the commercial availability and accessibility of needles in combination with health education about safe injecting practices and, in some cases, provision of free needles. Since 2001, the State Council has officially advocated needle social marketing as an HIV prevention measure. Evidence from research and study tours to countries such as Australia, [Bowtell W. Australia In: Yamamoto T, Itoh S, eds. Fighting a rising tide: the response to AIDS in East Asia, 1st edn. Tokyo: Japan Center for International Exchange, 2006: 19-52.] which runs successful needle exchange programmes, prompted the Ministry of Health to support the first such programme in
Yunnanprovince and Guangxi Zhuang Autonomous Regionin 1999. In 2000–02, a larger intervention trial of needle exchange programmes was done in four counties of Guangdongprovince and Guangxi, funded by the World AIDS Foundation. [Wu Z, Lin P, Liu W, Ming ZQ, Pang L. Randomized community trial to reduce HIV risk behaviors among injecting drug users using needle social marketing strategies in China. 15th International AIDS Conference; Bangkok, Thailand; July 11–16, 2004.] [Wu Z. Evaluation of a needle social marketing strategy for control of the HIV epidemic among injecting drug users in China. Final Report to the Word AIDS Foundation. Beijing: Chinese Academy of Preventive Medicine, 2002.] Cross-sectional data gathered at follow-up indicated that participants in intervention communities were almost three times less likely to have shared needles in the past month than those in control communities (odds ratio 0.36, 95% CI 0.25–0.52). Furthermore, rates of infection with hepatitis C viruswere significantly lower in the intervention arm than in the control arm (51.1% vs 83.6%, p=0.001) and HIV rates were lower in the intervention arm; however, this was significant only in Guangdong (p=0.011) and not in Guangxi (p=0.2) nor overall (18.1% vs 23.6%, p=0.391).
The results of the trial were used to develop national policy
guidelinesin 2002, and needle exchange programmes have been included in the second 5-year action plan. The programme was substantially scaled-up in 2006, from 93 sites to 729 by the year's end. Scale-up has been focused in rural areas, and in many places additional services are offered to IDUs, including condom distribution, voluntary counseling and testing, antiretroviral therapy, and educational information about drug use and HIV. [Liu B. Needle exchange programmes in China: effectiveness and factors associated with operation in two provinces. MSc thesis, Chinese Center for Disease Control and Prevention, 2006 (in Chinese).]
Methadone maintenance treatment programmes
A large body of international research has shown the efficacy of
methadone maintenance treatmentprogrammes for the treatment of drug addictionand subsequent reduction in HIV risk behaviors. [Sullivan LE, Metzger DS, Fudala PJ, Fiellin DA. Decreasing international HIV transmission: the role of expanding access to opioid agonist therapies for injection drug users. "Addiction" 2005; 100: 150-158.] [Gossop M, Marsden J, Stewart D, Treacy S. Reduced injection risk and sexual risk behaviours after drug misuse treatment: results from the National Treatment Outcome Research Study. "AIDS Care" 2002; 14: 77-93.] [Gibson DR, Flynn NM, McCarthy JJ. Effectiveness of methadone treatment in reducing HIV risk behavior and HIV seroconversion among injecting drug users. "AIDS" 1999; 13: 1807-1818.] [Marsch LA. The efficacy of methadone maintenance interventions in reducing illicit opiate use, HIV risk behavior and criminality: a meta-analysis. "Addiction" 1998; 93: 515-532.] In acknowledgment of this evidence, in 2004 the Chinese government called for the use of such practices to mitigate HIV transmission.In: Gill B, Morrison JS, Thompson D, eds. Defusing China's time bomb: sustaining the momentum of China's HIV/AIDS response. Washington: Center for Strategic and International Studies, 2004.] Immediately, under the governance of the Ministries of Health and Public Security and the State Food and Drug Administration, a pilot study of eight clinicsin five provinces was done. [Wu Z. Landmark government methadone maintenance program in mainland China. 15th International AIDS Conference; Bangkok, Thailand; July 11–16, 2004.] [Wu Z. Methadone maintenance program in mainland China: from pilot to scale-up. International Conference on the Reduction of Drug Related Harm; Belfast, UK; March 20–24, 2005.] Inclusion in the programme required: (1) several failed attempts to quit the use of heroin, (2) at least two terms in a detoxification centre, (3) age at least 20 years, (4) being a registered local resident of the area in which the clinic is located, and (5) being of good civil character. Those testing HIV positive need only fulfill criteria 4 and 5. To monitor the progress of the clinics, a database was established to gather data on demographics, medical issues, drug use, and other information about the patients. These data were assessed at 3, 6, and 12 months, and indicated reductions in heroin use, drug-related crime, and unemploymentin those who received methadone maintenance treatment.
On the basis of the successes of the pilot, the programme began scale-up in 2004 and plans are in place to open an additional 1500 methadone maintenance treatment clinics for about 300,000 heroin users by 2008. A National Training Center for methadone maintenance treatment has been established in Yunnan to provide clinical and technical support. The services offered at such clinics have been broadened and provide access to other services, including HIV and hepatitis testing, antiretroviral therapy for eligible AIDS patients, group activities, and skills training for employment. The use of methadone maintenance therapy has been incorporated into the AIDS Regulations as a treatment for
heroin addiction. Additionally, the requirements for entrance into methadone maintenance treatment programmes have been relaxed to encourage greater access. For example, patients are no longer required to have local residency or a previous history of internment in a detoxification centre. The programme is not without problems, however, and retaining drug users in the programme remains a critical challenge.
Although most HIV-infected individuals in China are drug users, patients infected through
sexualtransmission are the fastest growing group, accounting for close to 50% of new infections in 2005. Overall, they represent 43.6% of total HIV/AIDS cases, including commercial sex workersor their clients (19.6%), partners of HIV-infected individuals (16.7%), and men who have sex with men(7.3%). As with drug use, sexuality is not openly discussed in Chinese societyand is therefore neither easily targeted by health promotioncampaigns, nor has it traditionally been taught in schools. Even among university students, levels of AIDS knowledge and risk perception are alarmingly low. [Zhang H, Stanton B, Li X, et al. Perceptions and attitudes regarding sex and condom use among Chinese college students: a qualitative study. "AIDS Behav" 2004; 8 (2): 105-117.] [Li X, Lin C, Gao Z, et al. HIV/AIDS knowledge and the implications for health promotion programs among Chinese college students: geographic, gender and age differences. "Health Promot Int" 2004; 19: 345-356.] On the other hand, attitudes towards sex are becoming increasingly more liberal and, as a result, premaritaland extramarital sexare more commonly practiced. [Zhang K, Li D, Li H, Beck EJ. Changing sexual attitudes and behaviour in China: implications for the spread of HIV and other sexually transmitted diseases. "AIDS Care" 1999; 11: 581-589.] [Chen XS, Gong XD, Liang GJ, Zhang GC. Epidemiologic trends of sexually transmitted diseases in China. "Sex Transm Dis" 2000; 27: 138-142.] Although they are widely available, condomsare rarely used. [Yang H, Li X, Stanton B, et al. Heterosexual transmission of HIV in China: a systematic review of behavioral studies in the past two decades. "Sex Transm Dis" 2005; 32: 270-280.]
Commercial sex work
Commercial sex work is illegal in China; hence,
brothelsare illegal and commercial sex workers operate out of places of entertainment (e.g., karaoke bars), hotels, hair-dressing salons, or on the street.Gil VE, Wang MS, Anderson AF, Lin GM, Wu ZO. Prostitutes, prostitution and STD/HIV transmission in mainland China. "Soc Sci Med" 1996; 42: 141-152.] The traditional strategy for controlling HIV transmission through commercial sex workers has been the development of stricter laws to prevent risky behaviors, accompanied by raids on suspected sex establishments by public securityofficials. Those apprehended are subject to compulsory education on law and morality, testing and treatment for sexually transmitted diseases, and forced participation in productive labor. Under the Frontier Health and Quarantine Law, those knowingly infected with HIV who continue to practice prostitution are subject to more severe penalties and criminal liabilityfor creating a risk of spreading a quarantinable disease. Detention ranges from 6 months to 2 years. Until recently, health education in this system was uncommon.
In 1996–97, following the success of prevention interventions in neighboring
Thailand, [Anon. Thailand condom campaign reduced AIDS infections by fifty percent. "AIDS Wkly Plus" 1996; Aug 12, 19.] the Chinese CDC launched the first intervention projects to promote safer sex behaviors to prevent HIV and other sexually transmitted diseases in commercial sex workers working at entertainment establishments in Yunnan. [Wu Z. Final Report for Intervention on Female Prostitutes in Yunnan. Final Report to the World Bank. Beijing, China: Chinese Academy of Preventive Medicine, 1997.] [Wu Z. Promoting condom use among female prostitutes in natural settings in Yunnan, China. 12th International AIDS Conference; Geneva, Switzerland; June 28–July 3, 1998.] These projects showed the feasibility of such programmes, which included condom use to control the spread of HIV and other sexually transmitted diseases in commercial sex workers, and have been officially promoted since 1998. Between 1999 and 2001, the World AIDS Foundation supported a five-site trial of a behavioral intervention in commercial sex workers who worked in entertainment establishments. [Wu Z, Rou K, Li F, et al. Sustainability of effective STD/HIV prevention intervention targeting female sex workers and their clients at fice different settings in China. 14th International AIDS Conference; Barcelona, Spain: July 7–12, 2002.] Xinhua News Agency. [http://news.xinhuanet.com/english/2006-05/16/content_4554965.htm China to improve AIDS awareness among migrant workers] . Xinhua News Agency. May 16, 2006.] The intervention included condom promotion, establishment of clinics for sexually transmitted diseases to provide check-ups, and outreach for health education and counseling. HIV-related knowledge improved substantially, and the rate of bacterialsexually transmitted diseases fell. The rate of condom use at last intercourse increased from around 55% to 68%, and fewer commercial sex workers agreed to sex without a condom when requested by a client who offered more money. The prevalence of gonorrheafell from about 26% at baseline to 4% after intervention, and the prevalence of chlamydiafell from about 41% to 26%.
The findings from this trial were used to draft national guidelines for interventions among sex workers in China. The provision of condoms at entertainment establishments is now an official requirement under the AIDS Regulations. Condom vending machines are being installed in venues such as
university campuses and hotels, and condom promotion and HIV education campaigns that target youth and migrant workers are gradually being scaled up. [Xinhua News Agency. [http://news.xinhuanet.com/english/2006-02/26/content_4229253.htm Tianjin makes AIDS prevention education compulsory] . Xinhua News Agency. Feb 26, 2006]
Prevention of mother-to-child transmission
After reports of successful intervention in other
developing countries, [WHO Technical Consultation. UNFPA/UNICEF/WHO/UNAIDS Inter-Agency Task Team on Mother-to-Child Transmission of HIV. New data on the prevention of mother-to-child transmission of HIV and their policy implications. Geneva: World Health Organization, 2000.] a feasibility trialof the prevention of mother-to-child transmissionwas piloted in late 2002 concurrent with the antiretroviral therapy pilot, with financial and technical support from UNICEF. Mothers who tested HIV positive were offered counseling, the option of abortionor antiretroviral therapy and, where available, caesarean delivery, to reduce the likelihood of mother-to-child transmission. Free formula milkfor 12 months was provided for infants. [Wu Z, Sullivan SG. China. In: Yamamoto T, Itoh S, eds. Fighting a rising tide: the response to AIDS in east Asia. 1st edn. Tokyo: Japan Center for International Exchange, 2006: 76-95.]
On the basis of this pilot programme, national guidelines were developed to guide the prevention of mother-to-child transmission in the country. The provision of such services has been ratified by the AIDS Regulations. Services are being scaled up to cover at least 85% of infected pregnant women by 2007, and to reach at least 90% by 2010. Scale-up is being prioritized to the most heavily affected areas first. As of the end of 2005, more than 500,000 pregnant women in high-risk groups or in high-prevalence areas had been tested for HIV in 271 counties in 28 provinces. The overall participation rate in HIV testing in these pregnant women was 92%, and the HIV infection rate ranged from 0.3% to 0.7%. Among those who tested positive, 80% received antiretroviral therapy, and more than 90% accepted formula milk for the prevention of mother-to-child transmission. [Wang LH, Qiu X. Prevention mother to child transmission of HIV. In: Wang LD, ed. Epidemics of and responses to HIV/AIDS in the People's Republic of China. Beijing: Beijing Press, 2006 (in Chinese).]
A national program has been launched to combat the stigma and discrimination against people with HIV/AIDS.
*In 2006, 5,000 Beijing taxi drivers handed out HIV/AIDS information leaflets to passengers in the first 10 days of December.
*Officials in the southwestern province of
Yunnanannounced in 2006 that, starting on January 1 2007, Yunnan residents will be required by law to take an HIV testbefore marriage. There would be no charge for the test, the results of which are to be shared with prospective spouses. Yunnan, home to 25% of the country's HIV cases, borders the opium-rich Golden Triangle of Vietnam, Laosand Myanmar. The virus has been found in 128 of its 129 counties, the provincial government has said.
Future treatment options
:"See also: AIDS vaccine trials section below"In China, a distant hope for HIV prevention is the development of an effective
vaccinethat can offer long-term protection against the wide spectrum of HIV variants that exist. Despite the fact that there are now more than 30 vaccine candidates in clinical trials (in the world), and three of these are in advance stage testing (phase IIb and phase III), many obstacles still lie in the way of the development of a truly effective HIV preventive vaccine.
The genetic diversity of HIV presents an enormous challenge for researchers. And, because the
virushas the ability to evade neutralizing antibodiesproduced by natural immunity, the standard vaccine strategy of mimicking natural infection to induce antibodies has so far proved impossible. Strengthening cell-mediated immunity offers another possible route to success. About 90% of candidate HIV vaccines in development use this approach. These products will not prevent infection. But it is hoped that they will lower viral loadand therefore progression to AIDS and secondary transmissions. Some observers believe that a vaccine to prevent HIV will never be achieved. Ultimately, even if an HIV preventive vaccine were to be developed, they are unlikey to be 100% effective. It has come to be realised that no single approach alone will be able to stem the spread of HIV. The future of HIV prevention will most likely involve combining new methods with existing approaches, such as condomuse.
Newer approaches to HIV prevention
Unlike prostitution and drug use,
homosexualityhas never been banned in China, but it was listed as a psychiatric disorderuntil 2001, and public acts of homosexual sex are punishable as hooliganism.Liu H, Yang H, Li X, et al. Men who have sex with men and human immunodeficiency virus/sexually transmitted disease control in China. "Sex Transm Dis" 2006; 33: 68-76.] Although increasingly tolerated in the cities, in general, homosexuality is highly stigmatised and men who have sex with men are under considerable pressure to conceal their sexual orientation. [Choi KH, Liu H, Guo Y, Han L, Mandel JS, Rutherford GW. Emerging HIV-1 epidemic in China in men who have sex with men. "Lancet" 2003; 361: 2125-2126.] As a result, most homosexuals are married, or will be in the future, and form a bridge between the high-risk men who have sex with men group to their low-risk wives and other partners. [Qian HZ, Vermund SH, Wang N. Risk of HIV/AIDS in the People's Republic of China: subpopulations of special importance. "Sex Transm Infect" 2005; 81: 442-447.] [Choi KH, Gibson DR, Han L, Guo Y. High levels of unprotected sex with men and women among men who have sex with men: a potential bridge of HIV transmission in Beijing, China. "AIDS Educ Prev" 2004; 16: 19-30.] The government has initiated few interventions for men who have sex with men, leaving such programmes to advocacy groups, non-governmental organizations(NGOs), and researchers. [Zhang BC, Chu QS. MSM and HIV/AIDS in the People's Republic of China. "Cell Res" 2005; 15: 858-864.] However, the government recently estimated that there were 5–10 million men who have sex with men living in China, of whom 1.35% are thought to be HIV positive. [China Daily. [http://www.chinadaily.com.cn/hqylss/2006-04/05/content_560655.htm Chinese gay population announced for the first time] . China Daily. April 5, 2006.] This information, in addition to studies indicating low levels of HIV knowledge, perceived risk, and testing, and high rates of sexually transmitted diseases, [Jiang J, Cao N, Zhang J, et al. High prevalence of sexually transmitted diseases among men who have sex with men in Jiangsu Province, China. "Sex Transm Dis" 2006; 33: 118-123.] [Wong WC, Zhang J, Wu SC, Kong TS, Ling DC. The HIV related risks among men having sex with men in rural Yunnan, China: a qualitative study. "Sex Transm Infect" 2006; 82: 127-130.] has prompted the Ministry of Health to now include men who have sex with men in the high-risk groups and to call for the development of novel interventions to target them. [Wu Z. Overview of behavioural interventions in China. In: Wang LD, ed. Epidemics of and responses to HIV/AIDS in the People's Republic of China. Beijing: Beijing Press, 2006 (in Chinese).]
Private sector and NGO involvement
Since 2003, the central government showed an increasing openness on AIDS issues, making several public statements encouraging the participation of the private sector and, to some extent,
NGOs. This was due, in part, to the SARSepidemic, which helped change the way in which government dealt with public healthissues. For a prolonged period, the authorities did not admit to having a serious outbreak of SARS until it was a devastating problem and only then did they decide to come forward and acknowledge the real scale of the epidemic. The new-found frankness helped the government win back some credibility before the international community.
Currently, there are dozens of different projects sponsored by the private sector targeting the problem around the country, from education and awareness programmes to increasing the capacity of local NGOs. Notable cases include:
*Merck, a US pharmaceutical company, is spending about US$30m over a period of five years. The program involves training for healthcare professionals, condom distribution and identifying high-risk groups.
Bayer, a German pharmaceutical company, has set up a training course in HIV/AIDS issues for journalists. About 300 reporters have completed the course so far at Tsinghua Universityin Beijing.
Standard Chartered Bankhas introduced some of the approaches it has learned from its operations in southern Africa, including awareness programs for new employees and encouraging staff to be tested.
AIDS vaccine trials
China is currently seeking volunteers to participate in its second clinical trial of a new AIDS vaccine for early 2007, Shao Yiming, chief expert for the National Center for AIDS/STD Control and Prevention. The center is looking for men and women to participate in the trials which will take place in Beijing. He revealed the plan at a conference on Sino-U.S. AIDS vaccine research and development held on the 17 December 2006 without indicating how many participants will be involved in the trial. The vaccine was approved for clinical trials by Chinese drug authorities in November 2006. Trials on
Rhesus Monkeys indicates that the vaccine is safe and effective in preventing HIV infections, Shao said.
In March of 2005 China began its first human clinical trials on an AIDS vaccine in southwestern
Guangxi Zhuang Autonomous Region. The volunteers, 33 men and 16 women aged from 18 to 50, have been vaccinated and none have had adverse side effects.
According to a recent report released in 2006, there are 120 clinical trials of AIDS vaccines being conducted on humans throughout the world.
Public awareness and education
Public ignorance about AIDS is a major problem in China. A recent survey found 20 percent of people had never heard of the disease.
Testing campaigns were accompanied by community-level
social marketingto raise awareness of HIV and to reduce HIV-related stigma. The AIDS Regulations have outlined requirements for local governments at the county level and above, as well as for educational establishments, businesses, health providers, customsand border control, and the media to promote HIV/AIDS education and social marketing. A number of schools now include sex, drug, and HIV education for their pupils, especially in high-risk areas such as Yunnan, Guangxi, and Guangdong.
An important part of HIV education is targeting behavior to reduce stigma towards people with HIV/AIDS. Stigma is well recognized as a major barrier to HIV control, because it prevents people from seeking services for testing and treatment, and discourages people from practicing safer behaviors. [Malcolm A, Aggleton P, Bronfman M, Galvao J, Mane P, Verrall J. HIV-related stigmatization and discrimination: its forms and contexts. "Crit Pub Health" 1998; 8: 347-370.] [Yang H, Li X, Stanton B, et al. Willingness to participate in HIV/STD prevention activities among Chinese rural-to-urban migrants. "AIDS Educ Prev" 2004; 16: 557-570.] To address this issue, senior political figures have been involved in anti-discrimination campaigns, and have publicly shown that HIV cannot be transmitted through casual contact. For example, on World AIDS Day, Dec 1, 2003, Premier
Wen Jiabaopublicly shook hands with AIDS patients in Beijing Ditan Hospital.Watts J. China faces up to HIV/AIDS epidemic. "Lancet" 2003; 362: 1983.] The day before the 2004 World AIDS Day, President Hu Jintao and other senior government leaders visited patients living with HIV/AIDS and called for the elimination of bias against this group. [China Daily. [http://www.chinadaily.com.cn/english/doc/2004-11/30/content_396074.htm Hu visits AIDS patients in Beijing] . China Daily. Nov 30, 2004.] During the Chinese New Yearcelebrations in 2005, Premier Wen Jiabao visited the homes of HIV-infected villagers in Henanprovince. These actions had a tremendous effect on the general community, and have now been backed up by policy changes. The AIDS Regulations have made it illegal to discriminate against people living with HIV/AIDS and their families in terms of their rights to schooling, employment, health services, and participation in community activities. Furthermore, the AIDS Regulations and the 2004 revision of the "Law on the Prevention and Treatment of Infectious Disease" [Standing Committee of the National People's Congress. Infectious disease control act and HIV/AIDS act. Beijing, 2004 (amended) (in Chinese).] include language to protect the identity and disease status of those with an infectious disease, with disciplinary action recommended for those individuals or institutions that violate these laws. Although there had been language in previous regulations to protect the rights of people living with HIV/AIDS, these new laws give such individuals and their families a stronger basis from which to defend their rights.
Criticisms and control problems
Health officials say there are plenty of problems in China's approach to AIDS. There are frequent reports of police crack-downs on local NGOs involved in AIDS prevention. There have also been reports of police using the presence of a condom in a sex worker's handbag to justify detention. This has been partially blamed on policy incoordination, and contradictions and conflicts between laws and regulations.
In addition, there are concerns that provincial governments have enough autonomy to sometimes stall the implementation of central government-set guidelines and some officials say there has been a reluctance from many state-owned companies to get involved in AIDS programs.
Discrimination and stigma
Many Chinese businesses have been reluctant to make voluntary commitments to non-discriminatory treatment of HIV-positive employees, often because they fear lawsuits and because they are unable to recoup the cost of HIV/AIDS related health care from company insurance policies.
China speaks of the need for compassion and education to replace fear and ignorance in dealing with the epidemic. But the instinct to keep bad news hidden, to protect powerful officials from embarrassment, and protect the public image of the ruling Communist Party is still a powerful one in China.
Population movement and urban-rural inequality
China has made impressive progress in the development and implementation of effective intervention strategies, especially since 2004. The country is currently in a transition stage in its HIV policy development. It is increasingly adopting approaches that are based on scientific evidence and has encouraged the pilot testing of controversial methods of risk reduction (e.g., methadone maintenance treatment, needle exchange programmes, and the targeting of men who have sex with men and sex workers).
Failures in scaling-up HIV prevention programmes have not been caused by an absence of policy, but rather, as with other countries, by there being no policy enforcement and timely scale-up. Although China has a strong central government, provincial and lower levels of government enjoy a great deal of
autonomy, which has resulted in a mixed response and inconsistent enforcement of HIV/AIDS policy. For example, Yunnanprovince has shown strong support for implementation and advocacy of harm-reduction strategies that reduce HIV transmission in its many drug users, whereas Henanprovince had been slower to respond to the needs of former plasma donors in the early stages of the epidemic. [Watts J. AIDS in China: new legislation, old doubts. "Lancet" 2006; 367: 803-804.] Moreover, the distribution of HIV in China is not even, and is concentrated in areas with high drug use (e.g., Yunnan, Guangxi, Xinjiang, and Sichuan) and in areas where people were infected through unsafe blood or plasma donation (e.g., Henan, Anhui, Hebei, Shanxi, and Hubei). The number of cases ranges dramatically between provinces, with, for example, just 20 cases reported from Tibetbut well over 40,000 in neighboring Yunnan. In provinces with an extremely low prevalence, it can be difficult for officials to see the need for HIV prevention and control. Conflicts of interestbetween departments, such as those responsible for health and public security, have also made coordination of services to reach high-risk groups that engage in illegal behavior difficult. [Davis S. Restrictions of AIDS activists in China. "Human Rights Watch" 2004; 17: 1-57.] The central government has called for greater cooperation between relevant departments - including Public Security, Justice, Education, Civil Affairs, and Health - but implementation of this policy at the local level varies.
The problem is further exacerbated by inadequate resources and trained
personnel. Many rural areas - where most of China's HIV-positive population resides - do not have the capacity to monitor patients' CD4+ cell counts and viral load. In some cases, the physical infrastructure exists, but staff do not have the skills or reagentsto use it. Human resourcecapacity is a major constraint on China's ability to deliver HIV prevention and care. Many health workers and educators have poor knowledge of HIV and hold their own biases and stigmas towards those at risk or infected with HIV. [Wu Z, Qi G, Zeng Y, Detels R. Knowledge of HIV/AIDS among health care workers in China. "AIDS Educ Prev" 1999; 11: 353-363.] [Hesketh T, Duo L, Li H, Tomkins AM. Attitudes to HIV and HIV testing in high prevalence areas of China: informing the introduction of voluntary counselling and testing programmes. "Sex Transm Infect" 2005; 81: 108-112.] [Li L, Lin C, Wu Z, et al. Stigmatization and shame: consequences of caring for HIV/AIDS patients in China. "AIDS Care" 2006; 10: 463-471.] A substantial proportion of the funds allocated to HIV prevention and control is being spent on establishing training centers and in building the capacity of health workers so that they can deliver better services. But many of those willing to work in rural areas do not have formal medical qualifications to begin with, which limits their abilities to understand the complexities of treating HIV patients. [Yip R. Opportunity for effective prevention of AIDS in China. In: Kaufman J, Kleinman A, Saich T, eds. AIDS and social policy in China. Cambridge, MA, USA: Harvard University Asia Center, 2006: 177-189.] Furthermore, health services rely heavily on user fees, which often encourages health workers to do additional, chargeable services that many people living with HIV/AIDS cannot afford. [Zhang F, Hsu M, Yu L, Wen Y, Pan J. Initiation of the national free antiretroviral therapy program in rural China. In: Kaufman J, Kleinman A, Saich T, eds. AIDS and social policy in China. Cambridge, MA, USA: Harvard University Asia Center, 2006: 96-124.]
With an estimated 650,000 people living with HIV/AIDS and an ever greater number of people at risk of infection, the government has embarked upon a formidable task. The provision of accessible testing and treatment services not only requires financial resources, but also, in many cases, reorganization and supplementary funding of existing local health services infrastructure, especially in rural areas where most of Chinese HIV-positive individuals reside. [Ministry of Health of China. China's healthcare system and reform. Beijing: Chinese Ministry of Health, 2005: (in Chinese).] In particular, rural areas do not have adequately trained staff capable of providing effective treatment and prevention services, as well as the laboratory and clinical infrastructure necessary to monitor treatment. The problem of inadequate human resources is not restricted to health departments - in rural areas, there are few adequately trained technical and management personnel at all levels and across all sectors. The combination of insufficiently trained staff, inadequate technical resources, and a largely remote, poorly educated, rural population represents a challenge to the implementation of effective programmes.
A major step has been the government's promotion of
NGOs, [Xinhua News Agency. [http://china.org.cn/english/2006/Mar/162981.htm China encourages NGO's participation in fight against AIDS] . "Xinhua News Agency". Mar 23, 2006.] which are a new concept in China. [China Daily. NGOs act as bridge between government and people. "China Daily" Feb 23, 2006.] Many of the larger domestic groups are actually government funded, and those not affiliated with the government are required to go through a complicated registration procedure to be officially endorsed, although there might be a relaxation of these policies in the future. [He Z. Helping NGOs develop strength. "China Daily" May 28, 2005.] The presence of international NGOs is also increasing. The ability of NGOs to work with high-risk groups, especially those that engage in behaviors deemed to be illegal or immoral, and to provide care and outreach where overstretched health services cannot, is recognized. [Chen HT, Liao Q. A pilot study of the NGO-based relational intervention model for HIV prevention among drug users in China. "AIDS Educ Prev" 2005; 17: 503-514.] The private sectoris also being encouraged to undertake prevention and education activities. [People's Daily. [http://english.people.com.cn/200503/19/eng20050319_177468.html Chinese government invites private sector to join HIV/AIDS campaign] . "People's Daily Online". Mar 19, 2005.]
The mobilization of multiple sectors within China occurred over a 15-year period when there was a long series of educational workshops, conferences, collaborative projects, and networking between members at a number of levels of the government and administrative structural hierarchies. At local, national, and international forums, officials from many sectors were able to meet one another, share a common knowledge base, and debate the appropriateness of different interventions. Personal relationships were formed that facilitated the consideration and examination of previously unrecognised policy options for detection, prevention, and care. In a non-linear process, a consensus slowly evolved, identifying policy options.
Political officials, policymakers, administrators, and service providers were increasingly willing to recognize the relevance of a substantial body of scientific research that suggested effective intervention strategies that could change the course of the epidemic. Also, major policy recommendations with regard to behavioral interventions were preceded by small pilot projects that showed feasibility or efficacy in those populations at highest risk. Once the evidence base was documented, both the policymakers and politicians publicly showed their support for HIV prevention and care, as well as passing legislation to enforce and broadly disseminate health practices (e.g., routine HIV testing and access to care).
These processes occurred in a context of ongoing influences from the media and international donor agencies, with some contribution from advocacy groups within China. The SARS epidemic showed the potentially disastrous effect of a fast-moving infectious disease and, simultaneously, allowed the HIV community to acquire new methods to fight the epidemic (e.g., real-time data collection of new cases). However, mobilisation of resources, scientific evidence, and administrative drive did not occur until there was enthusiastic political commitment. The pace of implementation of innovative strategies for HIV detection, prevention, and care, accelerated with the commitments made by the government of
Hu Jintao, starting in 2003.
After a slow start and reluctance to recognize the existence of risk activities in its population and of the HIV epidemic, China has responded to international influences, media coverage, and scientific evidence to take bold steps to control the epidemic, using scientifically validated strategies. The country now faces the challenge of scaling up these programmes and of convincing all levels of government to implement these innovative strategies and policies. This vigorous response, incorporating research findings into policy formulation, can be informative to other countries that face similar challenges in responding to the
In China, like elsewhere, HIV/AIDS activists have played and continue to play an essential 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.
It has been claimed by some international human rights groups that HIV/AIDS activists in China continue to face serious obstacles in their work, including arbitrary detention, harassment and intimidation, and other human rights violations. Restrictions on travel by Dr.
Gao Yaojie, a Henan activist, have been cited in news reports. ["China Places AIDS Activist Under House Arrest" article by Jim Yardley in the New York Times, February 6, 2007.]
The country's best-known AIDS activist,
Wan Yanhai, believes China suffers 10 times the number of HIV cases - 650,000 - estimated by health officials.
Blood transfusion controversy
From the early to mid-1990s a network of businessmen and government workers, known as "bloodheads", set up hundreds of official and unofficial blood donation stations in
Henan Provinceto supply the market for blood plasmacreated by hospitals and manufacturers of health products. The common practice of reusing needles, not screening for diseases, sellers traveling from station to station with false records to maximize their income, and the mixing the blood prior to centrifuging and re-injecting the separated red blood cells back into the peasant blood-sellers guaranteed the rapid spread of blood-borne diseases such as HIV and Hepatitis B.Kellogg, Tom. [http://www.hrichina.org/public/contents/article?revision%5fid=1888&item%5fid=1887 Health officials seek to avoid responsibility for the spread of HIV/AIDS in rural Henan] . "Human Rights in China". February 23, 2003.]
The blood stations began to be closed down in 1995 when the scale of the HIV outbreak began to become apparent. The ensuing coverup saw government officials take credit for dealing with the crisis which they caused, the harassment of journalists attempting to cover the story, and of whole villages dying of what was to them a mysterious disease because they had not been informed that they were likely to have been infected.
In early December 2006, it was reported that a group of 19 people who contracted HIV from tainted blood transfusions at a hospital in the northeastern province of Heilongjiang were awarded 20 million yuan (US$2.5 million) in compensation. The landmark case involves the largest single group stricken by HIV in China. Eighteen of the victims will receive a one-off payment of $25,500 from the hospital and an additional $380 in monthly payments. Payment will go to the family of the one victim who has already died from AIDS. [Medical News Today. [http://www.medicalnewstoday.com/medicalnews.php?newsid=58367 19 HIV-Positive People In China Win Compensation From Hospital After Contracting Virus From Unscreened Blood] . December 8, 2006.]
The process of the impact of HIV/AIDS can be described as having three key stages: first, the impact experienced at the micro level; second, at the sectoral level; and finally, at the macro level. The impact began to be observed in China at the micro, or
householdlevel, 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. There has been almost no impact on the macro level. But if without effective preventive action, the HIV spread in the general population at large will have an impact on the macro level as have happened in some countries in sub-Saharan Arica. ["The Socioeconomic Impact of HIV/AIDS" Research Team. [http://www.unicef.org/evaldatabase/files/CHN_2001_006.pdf The Socioeconomic Impact of HIV/AIDS in the People's Republic of China] . UNICEF. August 2002.]
evere acute respiratory syndrome
The challenge of managing the
severe acute respiratory syndrome(SARS) epidemic (November 2002 to June 2003) is often credited with further motivating the government to take aggressive policy action on HIV-related issues. SARS showed not only how infectious diseasescould threaten economic and social stability but also the effect of China's policies on international health problems. Policymakers announced a change of focus from purely economic goals to increasing the focus on health and social wellbeing and, as a result, increased support for public health agencies. In controlling SARS, contact between the government and international agencies such as WHO, UN, and the US Centers for Disease Control and Preventionwas essential and further stimulated stronger international collaboration for HIV/AIDS prevention and treatment. Intervention strategies necessary for SARS control have been translated into HIV/AIDS prevention - e.g., real-time electronic case reporting.
The media have exerted substantial influence over the timing and course of HIV control in China by bringing news of HIV to the attention of the public, administrators, and policymakers. In 1996, the "
Southern Weekend" newspaper ran a front-page story and devoted another two pages to AIDS in China. This coverage was the first time any comprehensive exposure of the HIV/AIDS epidemic in China had been published by the Chinese press. From 1999, the international and subsequently the national media reported on the thousands of infected plasma donors in Henanand neighbouring provinces who did not have access to services. Although the government had acted quickly when the tragedy became apparent in 1995 by shutting down collection stations and, later, introducing new laws and regulations on the collection and management of blood and blood products, [Standing Committee of the National People's Congress. Blood donation law. Order number 93 of the President of the People's Republic of China. Beijing 1998 (in Chinese).] [State Council of People's Republic of China. Regulations for the management of blood products. State Council Document number 208. Beijing, 1996 (in Chinese).] provision of HIV testing, prevention, and care for donors in the local areas was slower. Progress was stimulated by the media's attention to the plight of the infected plasma donors. Since these initial reports, the HIV/AIDS situation in China has received much attention from the local and international media.
Ruby Yanghas recently 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, December 1 (Friday), 2006, and was rerun Sunday and Monday. It was viewed by around 400 million people. The 75-minute length documentary narrated by actors Will Smithand Glenn Close, had premiered in the United States in 2003.
:" [http://www.aidsportal.org/Article_Search.aspx?SID=5585&ATTID=8 AIDSPortal news summaries on China] "
On 25 November 2006, the
Associated Pressreported that a Chinese HIV/AIDS activist, Wan Yanhai, was apparently arrested shortly before an AIDS seminar was about to take place in Beijing.
Notes and references
*Gill B and Okie S. China and HIV — A Window of Opportunity. "N Engl J Med" 2007; 356(18): 1801-5.
*Chen HT, Liang S, Liao Q, Wang S, Schumacher JE, Creger TN, Wilson CM, Dong B, Vermund SH. HIV Voluntary Counseling and Testing among Injection Drug Users in South China: A Study of a Non-Government Organization Based Program. "AIDS Behav" Mar 9, 2007.
*Wu Z, Sullivan S, Wang Y, Rotheram-Borus M, Detels R. Evolution of China's response to HIV/AIDS. "Lancet" 2007; 369:679-690.
*Li X, Wang B, Fang X, Zhao R, Stanton B, Hong Y, Dong B, Liu W, Zhou Y, Liang S, Yang H. Short-Term Effect of a Cultural Adaptation of Voluntary Counseling and Testing Among Female Sex Workers in China: A Quasi-Experimental Trial. "AIDS Educ Prev" 2006 Oct; 18(5): 406-19.
*Hong Y, Stanton B, Li X, Yang H, Lin D, Fang X, Wang J, Mao R. Rural-to-Urban Migrants and the HIV Epidemic in China. "AIDS Behav" 2006 Jul; 10(4): 421-30.
*Wu Z. Sustainability of effective STD/HIV prevention intervention targeting female prostitutes and their clients at five different settings in China. "Final Report to the World AIDS Foundation". Beijing, China: Chinese Academy of Preventive Medicine, 2002.
*Su L, Graf M, Zhang Y, von Briesen H, Xing H, Kostler J, et al. Characterization of a virtually full-length human immunodeficiency virus type 1 genome of a prevalent intersubtype (C/B') recombinant strain in China. "J Virol." 2000; 74: 11367–11376.
*Zhang, K. AIDS. Bejing: PUMC Publishing House; 2000. pp. 1–4.
*Cohen MS, Ping G, Fox K, Henderson GE. Sexually transmitted diseases in the People's Republic of China in Y2K; back to the future. "Sex Transm Dis." 2000; 27: 143–145.
*Chen J, Zheng Z, Shao Y. Molecular-epidemiological analysis of HIV-1 initial prevalence in Guangxi, China. "Zhonghua Liu Xing Bing Xue Za Zhi." 1999; 20: 74–77. (Chinese).
*Liao SS. HIV in China: epidemiology and risk factors. "AIDS." 1998; 12 (suppl B): s19–s25.
*Chinese Ministry of Health; UN Theme Group on HIV/AIDS in the People's Republic of China. "China responds to AIDS—HIV/AIDS situation and needs assessment report." Bejing: Chinese Ministry of Health; 1997.
*Cohen MS, Henderson GE, Aiello P, Zheng H. Successful eradication of sexually transmitted diseases in the People's Republic of China: implications for the 21st century. "J Infect Dis." 1996; 174(s2): s223–s229.
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