Since acknowledging the HIV/AIDS epidemic,1,2 significant efforts to understand the epidemic in China have been undertaken resulting in a comprehensive policy response based on those understandings.3,4 From 2003 onwards, China has implemented ambitious treatment, prevention, and control programs, and significant resources to combat HIV/AIDS have been allocated, resulting in increased government infrastructure and capacity.3,4 Many successes have occurred since 2003; however, new challenges are emerging, and many previously identified challenges remain and continue to evolve. Although the research effort into properly understanding HIV/AIDS in China continues to expand, it is necessary to translate scientific findings into public health programs, which can be implemented nationwide. China does not yet have the luxury of complacency in its response to HIV/AIDS. This special edition of the AIDS Journal of Acquired Immune Deficiency Syndromes presents research into these new and continuing AIDS challenges.
New HIV/AIDS challenges emerging in China include transition from previously blood-driven HIV epidemic to now sex-driven HIV epidemic,3,5 the expanding epidemic among men who have sex with men (MSM),6,7 increasing drug resistance to antiretroviral therapy among new infections,8 the fast changing risk behaviors of high-risk populations,9,10 preventing mother-to-child transmission,11 and the potential for the HIV and tuberculosis (TB) epidemics to merge.12
Among the new HIV/AIDS challenges emerging in China, the expanding epidemic among MSM is undoubtedly the gravest of these new challenges regarding transmission of HIV.6,7,13 The number of MSM in China is considerable, and a large proportion of them also have unprotected sex with women; therefore, significant subgroups of MSM are a bridging group to heterosexual women who are presumed to be low risk. Several articles documenting HIV prevalence, risk behaviors, stigma, and a pilot program to increase condom use and HIV testing are presented here.13-15 Chengdu City, the capital city of Sichuan province, with a large population of MSM, seems to be an important city in the emerging MSM epidemic due to it attracting large numbers of domestic migrants and being a major stop on the heroin trafficking route through China. Two articles presented here investigating HIV/sexually transmitted disease prevalence and sexual risk behaviors and stigma in Chengdu found a HIV, herpes simplex virus-2, and syphilis prevalence rate of 9.1%, 24.7%, and 28.1%, respectively, and low condom use rates varying by partner type: 17.8% for steady female partners and 38.6% for casual male partners.7,15 Stigma and discrimination against HIV/sexually transmitted disease infection and homosexual behaviors were found to be significant barriers to HIV testing and treatment.15 In a study of nearly 5000 MSM in low prevalence regions of China, HIV prevalence was 2.9% and syphilis was 9.8%.13
Encouragingly a trial peer-driven behavioral intervention to increase condom use and HIV testing among MSM in Anhui province significantly increased HIV testing from 10% at baseline to 52.4% postintervention, although the increase in condom use was not as great (55.3% vs. 65.2%), and it was unsuccessful at reducing the number of sexual partners reported.14 The internet has revolutionized MSM interaction in China, and the full import of this is only beginning to be understood by public health professionals. An investigation into HIV prevalence, sexual risk behaviors, and internet use by MSM in Beijing and Urumqi is an important contribution to understanding the significance of the internet as a sex partner seeking venue.6 Results indicate that for MSM who use the internet, the internet was by far the most popular venue to find a sexual partner with 82% of participants using it to find sex partners, the next most popular venue, cafes and bars, were only used by 15% of participants.6 The implications of this are that outreach activities using traditional venues will not reach MSM who use the internet. The sexual and other risk behaviors of MSM in China have still not been comprehensively described, and it is anticipated that they will play a crucial role in the further transition of China's epidemic from being driven by injection drug use to sexual intercourse; however, the research presented here help shed light on this vulnerable, and important, risk group.
Regarding the treatment of HIV, the most concerning emerging challenge is expected to be increased future transmission of drug-resistant strains of HIV. In a sample of nearly 700 newly reported HIV infections from a variety of transmission modes in 2004-2005, the prevalence of HIV drug-resistant strains was low (3.8%); however, an increase in the transmission of high-level drug resistance was found.8
With the increase in sexual transmission of HIV and the majority of HIV-positive people living in China's countryside, preventing mother-to-child transmission will become more important over time. A trial intervention in rural Yunnan to prevent mother-to-child transmission, the province worst affected by HIV, had only a 1% seroconversion rate 18 months postdelivery and had a 96.3% survival 1 year after birth.11 Scale-up of the program nationwide should be feasible.
China has a high burden of TB, and there is concern that TB and HIV epidemics could merge. Research in Guangxi, a high TB and HIV prevalence province, found HIV prevalence was higher among TB patients than among the general population,12 therefore, in selected areas of China, programs to address TB/HIV coinfection are needed.
Continuing challenges include rural blood supply safety,16 providing appropriate support for children affected by HIV/AIDS,17 preventing further spread among female sex workers, the role migrant workers play in the epidemic,18 accessing difficult to reach high-risk populations, and having China-appropriate research tools.19-21
All HIV infections are tragic, and an especially tragic episode of the HIV epidemic in China was the infection of large numbers of rural commercial plasma donors in the early to mid-1990s through unsafe plasma collection practices.9 Because commercial plasma donation was outlawed in 1996, significant efforts have been made to increase the safety of the blood supply process, especially in rural China. In a study of the effectiveness of tests to ensure the safety of blood supply in 3 rural blood collection organizations, the sensitivity of the tests for hepatitis B surface antigen, hepatitis C virus, and syphilis were found to be inadequate, indicating much work on improving the quality of laboratory work remains.16
As the HIV/AIDS epidemic progresses, more children are affected by the disease through the loss of one or both parents. Research in Yunnan found children from HIV-affected families which experienced parental illness or death suffered from decreased school attendance and performance.17 In addition, children from HIV-affected families had lower levels of quality of life compared with child from non-HIV-affected families.17,21 China now needs to expand on the free schooling offered through the 4 Free's and 1 Care program to provide adequate support to the gradually increasing numbers of children affected by the epidemic.1-3
The sex industry in China is massive and varied. Although much work has been done to improve condom use rates among female sex workers (FSWs), as research presented here shows, consistent condom use with clients remains inadequate (58% in the past week), and FSWs are also at risk from regular and nonregular noncommercial sexual partners where condom use rates are usually much lower.22 Undoubtedly, efforts targeting FSWs to increase condom use must continue, but as research from migrant miners in Yunnan shows, where 72% of miners who had ever patronized a FSW had never used a condom with them, efforts must now be made to educate male clients of FSWs on the importance of condom use.18 In addition, efforts to develop a microbicide, the use of which is completely controlled by the female, must continue.23 Encouragingly, hypothetical acceptability of microbicides among FSWs and their male clients in a high HIV prevalence region of China seems to be high, however, caution must be taken if microbicides are brought to market to ensure they are not used as a substitute to condom use.23
Research instruments are critical to ensuring the quality of data collected. Information on the validity of the Mandarin versions of the fifth English version of the Addiction Severity Index and the PedsQL (pediatric quality of life) are presented.19
Finally, this special edition also includes 2 important articles documenting, in English, for the first time using government data, a comprehensive history of the epidemic in Yunnan,10 the epicenter of China's HIV/AIDS epidemic; and a thorough description of HIV prevalence among affected groups in Henan,9 the province most affected by unsafe commercial blood collection. The epidemic in Yunnan has undergone significant transformation since first being identified among injection drug users in 1989. By 2007, a total of 57,325 cases of HIV had been reported, and transmission has slowly evolved from injecting drug use long being predominant to sexual transmission in 2007 becoming the most common transmission route. The sociodemographic characteristics of people infected have changed with the share of rural infections decreasing dramatically, and the age range of infected people continues to increase as does the proportion of females. The early stages of the epidemic overwhelmingly affected ethnic minorities, but in 2005, the Han ethnic majority accounted for 63% of all infections. The epidemic in Yunnan is now classified as concentrated, and prevention efforts must change to target the sexual partners of higher risk groups. Given the complexity of ethnic groups, cultures and risk behaviors, containing HIV in Yunnan will remain challenging.
Data from 3 sources in Henan: the case reporting system, the sentinel surveillance system, and special surveys among former plasma donors (FPDs) were used to describe HIV prevalence in that province.9 By the end of 2006, a total of 35,232 HIV cases had been reported. Overall, HIV prevalence among identified FPDs was 8.6%. HIV prevalence among FPDs varied widely by county, with 0.09% the lowest recorded and 13% the highest. Sexual transmission among non-FPD risk groups is increasing, and HIV testing and increased condom use is suggested to reduce further transmission.
We hope this special edition will provide additional insights into the challenges facing China as the HIV/AIDS epidemic evolves. We also believe that China will able to adjust and tailor its responses and keep HIV/AIDS epidemic remaining in low rate.
Authors would like to thank Naomi Juniper for her valuable comments and suggestions.
1. China Ministry of Health, UN Theme Group on HIV/AIDS in China. A Joint Assessment of HIV/AIDS Prevention, Treatment and Care in China (2003)
. Beijing, China: China Ministry of Health; December 1, 2003.
2. State Council AIDS Working Committee Office, UN Theme Group on HIV/AIDS in China. A Joint Assessment of HIV/AIDS Prevention, Treatment and Care in China (2004)
. Beijing, China: State Council AIDS Working Committee Office; December 1, 2004.
3. State Council AIDS Working Committee Office, UN Theme Group on AIDS in China. A Joint Assessment of HIV/AIDS Prevention, Treatment and Care in China (2007)
. Beijing, China: State Council AIDS Working Committee Office; December 1, 2007.
4. Wu Z, Sullivan SG, Wang Y, et al. Evolution of China's response to HIV/AIDS. Lancet
5. Lu L, Jia M, Ma Y, et al. The changing face of HIV in China. Nature
6. Zou H, Wu Z, Yu J, et al. Sexual risk behaviors and HIV infection among men who have sex with men who use the internet in Beijing and Urumqi, China. J Acquir Immune Defic Syndr
7. Feng Y, Wu Z, Detels R, et al. HIV/STD prevalence among MSM in Chengdu, China and associated risk factors for HIV infection. J Acquir Immune Defic Syndr
8. Liao L, Xing H, Shang H, et al. The prevalence of drug resistance in treatment naïve HIV-infected individuals in China: 2004-2005. J Acquir Immune Defic Syndr
9. Li N, Wang Z, Sun D, et al. HIV among plasma donors and other high-risk groups in Henan, China. J Acquir Immune Defic Syndr
10. Jia M, Luo B, Ma Y, et al. The HIV Epidemic in Yunnan Province, China, 1989-2007. J Acquir Immune Defic Syndr
11. Zhou Z, Meyers K, Li X, et al. Prevention of maternal to child transmission of HIV using highly active antiretroviral treatment in Yunnan, China. J Acquir Immune Defic Syndr
12. Wang L, Liu W, Wang L, et al. HIV prevalence among pulmonary tuberculosis patients in Guangxi, China. J Acquir Immune Defic Syndr
13. Xiao Y, Sun J, Li C, et al. Prevalence and correlates of HIV and syphilis infections among men who have sex with men in seven provinces in China with historically low HIV prevalence. J Acquir Immune Defic Syndr
14. Zhang H, Wu Z, Zheng Y, et al. A pilot intervention to increase condom use and HIV testing and counseling among men who have sex with men in Anhui, China. J Acquir Immune Defic Syndr
15. Feng Y, Wu Z, Detels R. Evolution of MSM community and experienced stigma among MSM in Chengdu, China. J Acquir Immune Defic Syndr
16. Liu S, Figueroa P, Rou K, et al. Safety of the blood supply in a rural area of China. J Acquir Immune Defic Syndr
17. Xu T, Wu Z, Duan S, et al. The situation of children affected by HIV/AIDS in Southwest China: schooling, physical health and interpersonal relationships. J Acquir Immune Defic Syndr
18. Zhang G, Wang N, Wong M, et al. HIV-1 and STIs prevalence and risk factors of miners in mining districts of Yunnan, China. J Acquir Immune Defic Syndr
19. Luo W, Wu Z, Wei X. Reliability and validity of the Chinese version of the addiction severity index. J Acquir Immune Defic Syndr
20. Xiao L, Wu Z, Luo W, et al. Quality of life of outpatients in methadone maintenance treatment clinics. J Acquir Immune Defic Syndr
21. Xu T, Wu Z, Yan Z, et al. Measuring health-related quality of life in children living in HIV/AIDS-affected families in rural areas in Yunnan, China: preliminary reliability and validity of the Chinese version of PedsQL™ 4.0 Generic Core Scales. J Acquir Immune Defic Syndr
22. Li Y, Detels R, Lin P, et al. Prevalence of human immunodeficiency virus and sexually transmitted infections and associated risk factors among female sex workers in Guangdong Province, China. J Acquir Immune Defic Syndr
23. Wang Y, Jiang Y, Lu L, et al. Microbicide acceptability and associated factors among FSWs and male clients in Kaiyuan county, Yunnan Province, China. J Acquir Immune Defic Syndr