Over 22 years, China has experienced dramatic changes in the course of its HIV/AIDS epidemic and the government's response to it [1–3]. Cases began being identified in 1985, among foreigners and Chinese returnees. By 1989, the first indigenous cases were detected and by 1998, the disease had reached all 31 provinces and had affected at least eight different groups. As the severity of the epidemic has grown, so too has the government's response to it. This paper presents an overview of the HIV/AIDS epidemic, the government's response (particularly since 2003), and previous and current scientific research that is being used to guide the response to the epidemic in China.
Epidemics of HIV/AIDS
The epidemic of HIV/AIDS in China actually consists of several different sub-epidemics with sequential phases and some are intersected with others. In the first 5 years (1985–1989) several sporadic, non-indigenous HIV infections were detected. Identified cases did not number more than 100 per year (Fig. 1) and were confined to foreigners and Chinese who were infected by imported contaminated blood products or who had been infected while overseas. These infections are thought to have made little contribution to the later sub-epidemics of HIV infection in China.
The second sub-epidemic has been among injecting drug users (IDUs) driven by needle sharing and is likely to have been the core source for all later sub-epidemics in China. It started in 1989 with the detection of HIV among IDUs in Ruili County, Yunnan Province, adjacent to Myanmar – the major source of heroin and likely source of HIV . From there, HIV slowly spread to IDUs in nearby cities [5,6], provinces along the main drug trafficking routes [7–12] and finally, in 2002, to IDUs in all provinces throughout mainland China. As drug use continues to increase around the country, HIV infection through IDU remains the largest single cause of HIV infection in China .
The third sub-epidemic occurred among commercial plasma donors driven by collection contamination. In the 1990s, thousands of blood and plasma collection stations were established around the country typically offering 50 Chinese Yuan for plasma and 200 Yuan for blood. It is probable that the blood supply was initially contaminated by IDUs and failure on the part of the collection stations to adequately screen and separate donations resulted in thousands of infections. Authorities recognized the problem in early 1995  and evidence continued to grow thereafter; plasma donation was identified as a strong risk factor for HIV infection in Anhui , and high rates of HIV were found among children (suggesting mother-to-child transmission) in areas where the practice had been common . Fortunately, the magnitude of HIV infection among former plasma donors is much lower than was previously imagined. Screening in Henan in 2004 indicated an infection rate of 8.9% and screening in other provinces has similarly indicated lower than predicted rates of infection [16,17]. Moreover, the introduction of new laws to prevent this practice from continuing have meant that this source of infection has been more or less controlled. Most former plasma donors (FPDs) have been infected for up to 10 years and hence account for most of the known AIDS patients in China now.
However, a sizeable number of FPDs were infected and this sub-epidemic contributed to the fourth sub-epidemic which occurred among people who contracted the disease through blood transfusions, either from unscreened blood products before 1997 or through locally acquired blood during 1994 to 1998. Many of these cases have been reported from areas where plasma donation was popular in the 1990s. Together, infection among plasma donors and recipients of blood/blood products account for 10.7% of HIV infections in China .
The fifth sub-epidemic has been sexual transmission from HIV infected individuals to their spouses or regular sexual partners. This has been a major source of infection (16.7% of cases ). Two groups, spouses of infected drug users and spouses of former commercial donors, have been particularly affected. Among the spouses of IDUs, for example, evidence from Dehong Prefecture indicates infection rates increased from 2% in 1992 to 5% in 1993 to 12% in 1995 , then to 18% to 2004 (Dehong CDC, unpublished report, 2005). The HIV infection rate among spouses of HIV-infected commercial plasma donors was estimated at 4% in Henan province (Henan CDC, unpublished report 2004) and more than 20% in Hubei province (Hubei CDC, unpublished report, 2005).
The sixth sub-epidemic is driven by heterosexual activities, in particular commercial sex. Although the overall HIV infection among sex workers and patients with sexually transmitted diseases (STDs) is low, heterosexual transmission of HIV has increased alarmingly, nationwide. National sentinel surveillance data indicate that among 81 sentinel sites of STD patients, the proportion of sites detecting HIV infection has increased from 25.9% in 2003 to 45.9% in 2006, with individual sites reporting HIV infection rates of up to 9.7%. During this same period, among 36 sentinel sites of sex workers, the proportion reporting HIV increased from 33.3 to 44.4% and infection rates of up to 17%, indicating diffusion both geographically and in frequency (NCAIDS, unpublished report, 2006). This epidemic is thought to account for 19.6% of total infections .
The seventh sub-epidemic of HIV infection has been among men who have sex with men (MSM). This epidemic has only been recognized relatively recently and data describing it are limited. The Ministry of Health estimate that 1.3% of MSM are infected  and comprise perhaps 7.3% of total HIV infections .
Finally, the eighth sub-epidemic is among children. Another small but potentially growing group, infected by their HIV-positive mothers who comprise 1.4% of people living with HIV in China . This group is expanding, and in some areas of Yunnan and Xinjiang, the prevalence of HIV among pregnant women has been reported as being 1.3 and 1.2% respectively (NCAIDS, unpublished data).
The different sub-epidemics are based mainly on transmission modes, which provide a clearer understanding of how the overall HIV/AIDS epidemic has evolved. In actuality, these sub-epidemics are linked and interact with one another. For example, most female drug users are engaged in sex work and male drug users visit non-drug using sex workers more frequently than non-drug using males. Both groups contribute significantly to the heterosexual transmission of HIV between sex workers and their clients, then, further to their spouse or regular partners, and to the general public . Although the HIV/AIDS epidemic covers a broad range of populations, it remains concentrated in certain areas and in certain groups. For instance, HIV infection among adolescents and younger adults is mainly observed among young drug users and sex workers, while HIV infection among prisoners remains low except among prisoners who inject drugs. Figure 1 illustrates the overall HIV/AIDS epidemic in China. The first peak in the mid-1990s was caused mainly by plasma donation and blood transfusion. Since then, the epidemic's ongoing rising trend has largely been a result of heterosexual contact and intravenous drug use with a significant and increasing contribution by MSM, which remains a major challenge for China.
The overall course of the government's response to the epidemic could be summarized as: moving from denial to taking positive action; from policy advocacy to policy implementation; from a purely health-oriented response to a multi-government response, with greater involvement from non-governmental organizations; and from small demonstration projects/programs to countrywide scale-up.
The SARS epidemic in 2003 demonstrated to the government the impact public health could have on social and economic stability. After years of taking little action, a considerable increase in funding and a sincere commitment on the part of policymakers resulted in a change in China's HIV/AIDS response . Testing services were expanded and subsidised, anti-retroviral treatment was offered to AIDS patients, prevention of mother-to-child transmission began to be provided in high prevalence areas, special funds were allocated for counties hardest hit by the virus and a vigorous education campaign was launched to raise awareness about the disease . These changes were ratified in 2006 with the introduction of the Regulations on AIDS Prevention and Treatment and the promise of continued funding to execute the law. Funding has also been sought from international agencies, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank, UN agencies, and government aid (e.g. UK, US and Australian governments). In addition, help offered by international partners has been increasingly accepted in order to meet the government's goals.
Data collection for policy development
Under the direction of the Ministry of Health, the National Center for AIDS/STD Control and Prevention (NCAIDS) has been collecting and interpreting scientific data to inform HIV/AIDS policy formulation in China. Among the papers featured in this issue, are descriptions of the development of these systems as well as the early trials of behavioral interventions designed to limit the spread of HIV.
The National HIV/AIDS surveillance program has provided valuable data for monitoring trends in the epidemic and direct the government's response . Surveillance of the epidemic has been significantly enhanced since the government established online case reporting in 2005 to collect data on all diseases, including HIV. The system allows daily updates of newly diagnosed cases as well as behavioral surveillance data and anti-retroviral treatment and drug resistance monitoring. These data have been linked with each other as well as other existing data sets (e.g. enrollment in methadone treatment). While these data provide valuable information about the epidemic, uptake of HIV testing remains low and possible reasons for this have been evaluated by Ma and colleagues on pages S129–S135 .
In 1996–1997 NCAIDS conducted the first community-based trial of an intervention specifically designed to prevent HIV transmission. The target group were establishment-based female sex workers (FSW) and the trial, described on pages S89–S94 , was designed to promoted condom use and increase HIV and general sexual and reproductive health knowledge among the FSW [23,24]. It demonstrated the feasibility and efficacy of such programs and as a result, condom use to control the spread of HIV and other STDs among FSWs has been officially promoted since 1998. Later, between 1999 and 2001, NCAIDS oversaw the conduct of another trial with sex workers, summarized on pages S95–S101 [25,26]. In this second, much larger trial, five sites were chosen, each with different forces driving their epidemic. The trial was able to demonstrate that a standardized intervention model could be successfully applied to widely disparate settings within China and thus was recommended to inform the development of guidelines for conducting condom promotion among FSWs, nationwide.
The China CDC later began evaluating interventions for IDUs. The first needle exchange program was piloted in Yunnan Province and Guangxi Autonomous Region in 1999, and later a larger trial was conducted in Guangdong Province and Guangxi Autonomous Region . Cross-sectional data collected 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 and had significantly lower rates of hepatitis C. Needle exchange programs have since been expanded and have helped reduce risky injecting behaviors in areas where they have been implemented. However, as described by Liu and colleagues on pages S123–S128 , the programs still face many challenges to effective implementation, the most important being in creating partnerships with local police and offering more flexible working models to maximize coverage.
In 2004, further interventions for IDUs began to be explored and the country's first methadone maintenance treatment program was piloted. China's drug users are overwhelmingly heroin users and thus methadone could help to significantly reduce HIV infections between drug users by treating their addiction. To this end, the Ministries of Health and Public Security and the State Food and Drug Administration joined forces to pilot China's first methadone treatment program. Eight clinics were established and surveys were conducted before the clinics were initiated and approximately 6 and 12 months later to measure the program's effectiveness. The evaluation by Pang and colleagues (pages S103–S107 [29,30]) indicates significant reductions in heroin use, drug-related crime, and unemployment among methadone clients. As with the other interventions, this program is currently being scaled-up nationwide.
In addition, scientists have used molecular epidemiology to understand the epidemic, as is described by Zhang and colleagues about the MSM population in Beijing on pages S59–S65 . The National HIV Reference Laboratory at NCAIDS has been busy refining the techniques needed to monitor the progress of both the epidemic and the government's treatment program (described on pages S27–S32 ).
The Division of Treatment and Care at NCAIDS who oversee the ART program in China have provided an overview of the program and the problems within (pp. S143–S148 ). The program was initially established to help former plasma donors as more and more were developing AIDS. The program is expanding to reach all groups affected by AIDS but is hindered by a number of challenges. Among certain groups, however, it would seem that a majority of patients are able to their treatment, such as the former plasma donors of Anhui province that were studied by Wang and Wu (pp. S149–S155 ).
Data on emerging risk groups are also presented in this issue, including the so-called ‘floating population’ – the approximately 130 million migrant workers who typically come from poorer regions of the country and work in the cities as laborers, restaurant workers and sex workers . He's study on pages S73–S79  compares risk factors among two groups of male migrants – those engaging in sex work and those working in other work. Mi and Wu also present a qualitative look at the working conditions and risks faced by male sex workers (pp. S67–S72 ). Increased understanding of the epidemic among MSM has also been explored (pp. S53–S57 ).
Tian et al. (pp. S137–S142 ) have explored one of the major challenges inherent in the healthcare system – ignorance and misunderstanding among healthcare workers. The results of web-based training designed to raise HIV awareness and understanding among local health workers are encouraging and should be used widely.
Although the progress described in this issue is promising, there remain several major challenges to effective control of HIV in China. Stigma and discrimination continue to hinder the uptake of testing services, enrollment in the ART program, acceptance of behavioral interventions and identification of key populations. As a result, many people living with HIV/AIDS do not know they are infected and many of those at-risk of infection are taking inadequate measures to protect themselves. Limitations within the healthcare system also exacerbate these problems, with insufficient coverage of testing, treatment and prevention services. Multisectoral responses are needed and more needs to be done to increase understanding and support from relevant agencies, particularly public security.
The Chinese government has demonstrated its commitment and willingness to take action to control HIV/AIDS. They have identified the most at-risk groups and outlined pragmatic guidelines for behavioral interventions. Recognizing the conflict that exists between the various departments involved, guidelines have been issued that instruct local staff to seek cooperation from the departments of public security and industry and commerce, among others, to reach members of targeted populations, many of whom are marginalized and can be difficult to find. As Premier Wen Jiabao said ‘China is still facing serious challenges in HIV/AIDS prevention and control, but the Chinese government is determined and capable of curbing the spread of the disease to ensure the people live a healthy and peaceful life.’
The author thanks Ms. Sheena G. Sullivan and Dr. Zunyou Wu for their valuable comments and suggestions.
The author reports no conflicts of interest.
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