HIV Around the World - China

The World’s Oldest Civilization and How It’s Dealing with HIV and AIDS

China is one of the oldest civilizations in the world. Their way of life is built upon tradition and Chinese culture. How does a culture dating back 6,000 years deal with an epidemic that emerged less than 30 years ago?

China - Demographics

Here are some facts about China:
  • located in Eastern Asia
  • geographically, it's one of the largest countries in the world, with an area of approximately 9.6 million square kilometers (slightly less than the United States)
  • population of approximately 1.3 billion people, which equals about 20 percent of the world's total population
  • comprised of hundreds of ethnic groups speaking dozens of dialects and languages
  • no government recognized religion but personal religion and religious organizations are allowed
  • primary religions are Buddhism, Taoism, and Confucian
  • deep-seated ancient traditions provide the foundation of Chinese culture

The Status of HIV in China

Here are some facts about HIV and AIDS in China:
  • as of January 2006, the "official" estimate is that approximately 650,000 people are living with HIV and 75,000 living with AIDS. Experts outside China believe the actual numbers are much higher than those endorsed by the Chinese government.
  • there are an estimated 70,000 new HIV cases and 25,000 AIDS deaths each year

The exact extent of the HIV epidemic is difficult to assess due to government road blocks. Local governments as well has national government entities are hesitant to place a hard number on the epidemic for fear of discrimination and stigma.

Those citizens who know what HIV is are reluctant to come forward for testing for fear of retribution if they are found to be positive. Most people don't get tested because they know little or nothing about the existence of HIV. It's estimated that 17 percent of Chinese citizens don't know HIV exists.

The number of rural HIV cases is nearly impossible to quantify accurately. The shortage or absence of testing supplies and the very limited number of trained testing staff makes diagnosis very difficult. The rural areas of China are very poor with very limited education. Those who do know about HIV don't get tested because of the stigma associated with a positive diagnosis.

The History of HIV in China

In China, the HIV epidemic started slowly in the mid 1980's. A small number of HIV cases were diagnosed primarily in coastal communities. Chinese officials attributed the outbreak to foreign visitors and Chinese students returning from studying around the world. The Chinese government posted official warnings for Chinese women not to have sex with who the government called "foreign visitors" because they may be infected. Simply put, China felt that HIV was someone else's problem.

The official government stance on HIV was that the risk to China was very limited. HIV was thought to be a predominantly homosexual disease and the government felt that in China, homosexuality and "abnormal sex" was a limited problem.

Beginning in the late 80's and early 90's, HIV infection emerged as a growing problem among intravenous drug users. Still, the government felt that HIV was a "disease of the West," as was their emerging drug problem. HIV was labeled "a capitalism disease" and one that China was not part of.

But from the mid 90's to early 2000, HIV began to spread across all Chinese provinces. The culprit for such a widespread problem was determined to be an unsafe blood supply.

The Chinese government contracted commercial blood collection centers across China. While there were guidelines in place to assure quality, many of the private collection centers cut corners in order to increase their profits. Their collection techniques exposed thousands of people to HIV. Collection equipment was routinely used on multiple patients and blood collected from several donors was pooled. Officials separated the blood components they needed and then re-infused what was left of the pooled blood back into donors, thereby exposing donors to HIV, hepatitis C and other blood-borne illnesses.

By 2000, fueled primarily by the unsafe blood supply, the number of HIV cases ballooned, prompting the Chinese government to lift its unofficial policy of HIV silence and denial.

A Culture of Sexism

As mentioned, much of Chinese culture is based on ancient traditions. One such tradition is sexism and the discrimination against women. Sexism is present both institutionally and individually. The fair and equal treatment of women is contradictory to cultural and religious beliefs. Sexism is so entrenched that many teachings ask the rhetorical question, "are women fully human"? Many question if men and women have equal virtues.

Even in an economic sense, sexism is prevalent. Women are seen as competition for the male workforce. Sexism has even permeated the choice to have children. The practice of gender selective abortion is such a common practice that the ratio of male babies to female babies is widening. Sexism impacts the extent of the HIV epidemic by dictating how people are educated about HIV and who makes the decisions regarding safer sex practices.

Page two discusses who is infected, the state of HIV prevention, and what HIV care is available.

Who's Infected?

As is common in many parts of the world, HIV has gone from a disease of people in a few high risk groups to a disease that is found in every population. Still, these high risk groups account for most of the country's infections.
  • IV Drug Users - In a country where about three percent of its citizens are IV drug users, those people account for about 60 percent of all new HIV infections. China has a zero tolerance drug policy meaning anyone caught using IV drugs has to go to mandatory incarcerated drug rehabilitation. One would think such an environment would be a perfect way to educate about HIV. However, the implementation of HIV and AIDS education programs as part of drug rehab has been slow. Prevention messages have been limited to a few posters explaining HIV risk and prevention.
  • Blood Products - Despite all the problems with the Chinese blood supply in the past, the government continues to prohibit the importation of blood products. Blood donor centers are driven by profit, meaning that many of the commercial centers cut corners to make more money, even if it means breaking the law. It's estimated that about 10 percent of all new infections are from infected blood products. Compare that to the U.S., whose infection rate from blood products has been eliminated, and you understand what a big problem the tainted blood supply is in China.
  • Sex Workers - The growing problem of prostitution in China is fueled mostly by economic need. Prostitution is illegal in China with government sponsored "rehab" facilities for those women caught taking money for sex. However, the rehab centers primarily teach the evils of prostitution and not the health risk that prostitution poses to the women involved. Condom use is erratic. Women have been arrested for carrying condoms, assumed to be a sign of prostitution. Because of this, sex workers seldom initiate condom use. This combined with culturally acceptable sexism prevents most women from taking the lead in safer sex practices.
  • Men Who Have Sex With Men (MSM) - While homosexuality is not illegal, it does carry significant stigma. It is this stigma that decreases the accessibility to safer sex information and HIV education. Gay men feel there is no safe haven for them to discuss risks and concerns. Gay men are encouraged to suppress their homosexuality and marry women. Many do but continue to have unsafe sex with other men, placing their wives at considerable risk when they have sex within the marriage. While MSM do not account for a large number of HIV cases now, about half of all MSM practice unsafe sex, so experts fear this will cause a sharp increase in the number of new HIV cases very soon.
  • Migrants - China's 120 million migrants are very mobile, moving across the country wherever the work takes them. This mobility makes them vulnerable to HIV. Traveling to new, unfamiliar places, migrants are reluctant to access HIV prevention services if there are any. They may travel to areas where condoms are scarce or difficult to access. In addition, many migrants are young single males. The money they earn is significant and is sometimes used for drugs and prostitutes in order to combat the loneliness of being on the road. Those men who are married, come back from their travels and place their wives at risk by having unsafe sex with them after having unsafe sex on the road.

HIV Prevention

Not until 1998 did China have a national, long-term plan to combat HIV. The notion of condom ads was quickly shot down by the Chinese government after an ad played one time on the national television network in 1999. Condoms were viewed as illegal sexual tools by China's State Administration of Industry and Commerce and were banned from the airwaves. That ban persisted until 2001 when the Chinese Ministry of Health reclassified condoms as "medical devices" instead of a sexual commodity. Still, condoms are not an acceptable part of mainstream China, they are in short supply and are of poor quality.

Recently it was reported that circumcision can be an effective way to reduce the risk of HIV transmission. The belief is that circumcision could be a good choice for those countries like China that have limited resources to devote to condom education and distribution. However, an article in the China Daily reported that officials were not sold on the benefits of circumcision and would not officially condone the practice.

Risk-reduction education and needle exchange programs are expanding across China. The Chinese government has mandated that HIV education and awareness efforts were to be directed to the general public in an effort to reverse prejudice and stigma. In 1998 China promised to launch HIV curriculum in schools however to this day no such program is in place.

High risk groups continue to be made scapegoats of the HIV problem. Gay men have no refuge from the prejudice, severely interfering with efforts to educate that population. Groups that wish to sponsor or launch public HIV education campaigns are reluctant to do so for fear of severely damaging their public image.

The State of HIV Care

Despite rising HIV rates, very few are able to get basic HIV care. The government encourages production of domestic versions of some HIV drugs; however, these have been found to be scarce and of poor quality. For those who have access to these drugs, the side effects are dramatically worse than the patented versions, making adherence difficult. By 2004, only about 12,000 people were taking HIV meds regularly.

The government has initiated what they call Four Frees and One Care Policy. The initiative consists of:

  • Free meds for rural and financially troubled urban areas.
  • Free HIV testing and counseling.
  • Free medications to infected pregnant women.
  • Free school for children orphaned by HIV and AIDS.
  • HIV care and economic assistance for those living with HIV.

While the notion is a good one, making it a reality is a long way off.

Sources:

Kanabus, A.; ""HIV/AIDS in China"; Avert.org; 10 Feb 2007.

Li, Chenyang.; "The Sage and the 2nd. Sex: Confucianism Ethics and Gender." Open Court 2000. 17th. Edition; Chicago 2000.

U.S. Department of State.; "Background Note: China"; Washington DC: 01 Jan 2007.

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