From the aDepartment of Epidemiology, University of California Los Angeles (UCLA), School of Public Health, Los Angeles, California, USA
bDepartment of Epidemiology, School of Public Health, University of Alabama, Birmingham
cChinese Ministry of Health, Beijing, P.R. China.
Correspondence to Roger Detels, Department of Epidemiology, University of California Los Angeles (UCLA), School of Public Health, Box 951772, Los Angeles, CA 90095-1772, USA. E-mail: email@example.com
This special issue of AIDS documents the remarkable progression of the response of China to the HIV/AIDS epidemic, from initial denial to one of the more vigorous and comprehensive responses of any nation. Starting in 2003, China has initiated ambitious programmes to prevent the spread of HIV beyond the initially involved groups, injection drug users, former plasma donors, and more recently, sex workers. The response of the government of China results from the recognition of the work and commitment of researchers, health professionals, concerned community advocates, and the media, who recognized the seriousness of the HIV/AIDS epidemic and worked to stimulate a broad response by the government.
The programme initiated by China is broad in scope and has implemented many strategies to confront and prevent a generalized epidemic, including basic research, surveillance, HIV testing, stigma reduction, harm reduction, control of sexually transmitted diseases, access to treatment, and efforts to promote compliance with medications. They have implemented routine testing of risk groups, with referral to treatment for those found to be infected, initially a controversial decision, now supported by most HIV/AIDS professionals. In an effort to reduce stigma, China has passed laws to enforce the rights of HIV-infected individuals and risk-group members. Researchers have demonstrated the effectiveness of drug replacement therapy, needle social marketing and condom promotion, which has been recognized by the government. China now has more drug replacement clinics and needle social marketing programmes than any other country in Asia and southeast Asia. China has stated its intent to provide HIV treatment for all who need it by implementing treatment clinics in all the major areas affected by the epidemic.
Despite this vigorous approach, several issues remain to be addressed. First, there is the challenge of convincing the local governments to implement the wide-ranging policy decisions of the central government that target all of the principal risk populations. Second, there is an urgent need to develop the infrastructure and personnel to implement these policy decisions. Third, as documented in this issue, there is a problem with achieving optimal adherence to antiretroviral therapy to diminish the emergence of drug resistance. Fourth, resistance and toxicity to first-line drugs will create a demand for second- and third-line drugs that will require more sophisticated medical management. Fifth, stigma remains a problem, reducing willingness to be tested, resulting in individuals at risk choosing to remain hidden. Sixth, the epidemic in men who have sex with men is complex, still understudied, and may play an important role in transmission to other segments of Chinese society. Seventh, treatment programmes for illicit drug addiction are still inadequate to cover the full need in China. Finally, sex work in China is diverse, and it remains difficult to cover all sectors with adequate education and risk-reduction tools, such as condoms and sexually transmitted disease services. All of these problems are made more difficult because the majority of HIV-infected individuals are in the resource-limited rural areas, in contrast to most other regions of the world, where urban areas have the most infected individuals.
History has documented that once China decides to address a problem, the nation is capable of taking massive action. These remaining problems can thus be addressed successfully. Although there has been considerable criticism of China's response to the HIV epidemic in the past, the papers presented in this special issue of AIDS indicate that the Chinese are to be commended for the vigorous and comprehensive response they have now implemented. We hope that this special issue on China's response to the epidemic will provide new insights into HIV control. We further hope that China, with one in every five individuals on the planet earth, will reverse the direction of its growing epidemic and join Uganda and Thailand as a model of success.