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Special article

An overview of the history of epidemic of and response to HIV/AIDS in China: achievements and challenges

CUI, Yan; Adrian, Liau; WU, Zun-you

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doi: 10.3760/cma.j.issn.0366-6999.2009.19.013
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Since the first case of acquired immunodeficiency syndrome (AIDS) in China was identified and reported in 1985, the country has experienced dramatic changes in the course of its human immunodeficiency virus (HIV)/AIDS epidemic along with the government's response to it in the past 24 years.1,2 As the severity of the epidemic grew, so too has the government's reaction to it. This paper presents an overview of the HIV/AIDS epidemic; the government's response, particularly changes in political commitment, policy environment and intervention strategies, and achievements made since 2003; and the challenges ahead to keep China at a low HIV/AIDS epidemic level. This review only contains information from the mainland of China.

EVOLUTION OF HIV/AIDS EPIDEMICS

Change of magnitude

The first HIV infection was probably introduced into China in 1985.3 In 1995, the number of individuals identified with HIV infection in China equaled the cumulative total of those reported between 1985 and 1994. From 1995 to 2000, the average increase in reported HIV infection was about 30% annually. HIV infection rates continued into the 21st century with a larger than usual increase reported among HIV-positives during 2004 due mainly to intensive screening of former plasma donors (FPDs) as well as expanded and strengthened surveillance and testing (Figure 1).4 The HIV infection rate among China's population is currently 0.05% (range: 0.04%-0.07%), making it a low HIV prevalence country. The epidemic continues to expand, but the rate is slowing.

Figure 1.
Figure 1.:
Annual reported HIV and AIDS cases in the mainland of China from 1985 to 2008.

Geographic movement

China's geographic movement of HIV is characterized by the initial spread of the infection in rural areas before moving to the urban areas. The first outbreak of HIV infection was observed in the rural areas bordering between China and Myanmar in 1989, specifically Ruili County, Yunnan Province.5 As the infected group consisted mostly of injection drug users (IDUs), the transmission continued slowly to nearby cities and provinces along major drug trafficking roads.6 Around the mid-1990s, rural communities in several communities started getting HIV infections through commercial plasma donations;6 for instance, plasma donation was identified as a strong risk factor for HIV infection in Anhui Province.7 By 1998, all provinces reported cases of HIV infection. Latest figures (October 2007) showed that 74% of counties/districts reported HIV positive people with 80.5% of people living with HIV reported in Yunnan, Henan, Guangxi, Xinjiang, Guangdong and Sichuan (Figure 2).4

Figure 2.
Figure 2.:
HIV/AIDS moving geographically in mainland of China over time. First AIDS was reported in 1985 (green), all provinces in the mailand of China reported epidemic by 1998.

Movement across sub-populations

The evolution of HIV/AIDS epidemic in China has clearly documented the movement of the infection across different groups of the population. The first groups to be affected were Chinese citizens who were infected while abroad and had returned to China, and hemophiliac patients who used imported contaminated blood products. These infections are thought to have made little impact to the later HIV epidemic in China.

The second major group, and still affected the most, is IDUs. This group is likely to have been the core source for all later transmissions in China. The first outbreak of HIV infection among IDUs was reported in 1989. By 2002, HIV infections within this group were reported from all 31 provinces in mainland of China. As drug use continues to increase around the country, HIV infections among IDUs remain the largest single cause of HIV transmissions in China.2 This group is also more likely to be infected with other sexually transmitted diseases (STDs), including hepatitis B and C.8

The third major group is FPDs through commercial means and blood recipients in the mid-1990s. From late 1980s to early 1990s, thousands of blood and plasma collection stations were established around the country, particularly in the least developed rural areas of central China. Typically, one unit of donation was paid in 50 RMB for plasma and 200 RMB for whole blood. Without HIV screening, some 69 000 FPDs and blood recipients were infected with HIV through contamination of plasma and blood. Together, infection among FPDs and recipients of blood products account for 10.7% of HIV infections in China.2 Fortunately, the magnitude of HIV infection among FPDs is much lower than was previously thought.

The fourth major group is spouses or regular sexual partners of HIV infected individuals who got infected through having sexual intercourse with their partners. This has been a major source of infection (16.7% of total cases), although it is unlikely to be a major driving force for large scale diffusion of the virus.2 Two sub-groups, spouses of infected drug users and spouses of former commercial donors, have been particularly affected.

The fifth major group is clients of female commercial sex workers (CSWs). Although the overall HIV infection rate among sex workers is low, heterosexual transmission of HIV has increased greatly nationwide. This epidemic is thought to account for 19.6% of total infections.2

The sixth and seventh major groups were men who have sex with men (MSM) and babies born from infected mothers. The epidemic among MSM has only been recognized relatively recently and data are limited. The Ministry of Health estimates that 1.3% of MSM are infected and this comprises roughly 7.3% of total HIV infections.2,9 The epidemic among children is a small but potentially growing group who were infected by their HIV-positive mothers; they comprise 1.4% of all HIV infections in China.2 With the expansion of preventive measures in transmissions from mother-to-child, the risk of HIV infections among new-born infants have decreased dramatically.

New HIV infections

Knowledge on the number of new HIV infections is critical to understanding the movement of the ongoing epidemic. Unlike acute infectious diseases, most newly identified HIV infections are actually not recent contractions but are infections from a few to many years ago. The most common strategy to collecting such information is to conduct cohort studies. Using new laboratory technological developments, a rough estimation of new HIV infections based on cross-sectional surveys can be made.10 Unfortunately, limited information about new HIV infections in China is currently available. The few cohort research studies available showed that the incidence of HIV was about 8% in Yunnan and 3% in Guangxi and Sichuan.11-13 Cohort of drug users in MMT programs has an overall 0.7% sero-convertion rate.14 Cohorts on MSM in Beijing revealed a 5% incidence of HIV infection. Based on all available data, the first estimation of HIV new infections of 70 000 was made in 2005.9 As of October 2007, the estimated new HIV infections in 2007 was 50 000 (range 40 000-60 000), about 20 000 fewer new infections from two years ago.

AIDS mortality

With rapid development of anti-retroviral therapy treatments (ART), AIDS fatality has decreased dramatically. The fall in drug prices has made ART more affordable to AIDS patients. However, the annual number of reported HIV/AIDS deaths has increased steadily over the past several years and HIV/AIDS is now the number one cause of death among all infections in China. Because of underreporting, the actual number of AIDS death might be higher. In total, there are an estimated 20 000 AIDS-related deaths (range 15 000-25 000) as of October 2007, with 4232 deaths reported during the first ten months of that year.4

EARLY RESPONSES

After the HIV epidemic was reported in the Western world, the Chinese government banned HIV-infected persons from entering the country,15 with similar rules applied between provinces to some extent. By 1991, all AIDS cases had to be notified to the local health authority, and that AIDS patients must be quarantined.16 In time, implications for applying the law to the reporting of AIDS cases proved confusing and the quarantine of AIDS patients unfeasible. Additionally, education and prevention have been emphasized as priorities for AIDS control from the very first reported HIV case in China. In practice though, they were not given adequate attention; few effective educational intervention measures targeting high-risk groups were implemented. The support for laboratory and epidemiological research was also low.

STRATEGIC CHANGES AND ACHIEVEMENTS MADE

Strong commitment

In the past 15 years, the central government has been giving more attention to HIV/AIDS prevention and control. All respective local governments and sectors were requested to implement HIV/AIDS prevention and control work from the perspective of protecting public health and economic development, and the future state of the nation.17 As a start, CHEN Min-zhang, ex-Minister of Health, participated in the AIDS Summit in Paris, France in 1994. As the delegate of the Chinese Government, ex-Minister CHEN signed the “Paris Declaration”. In 2001, ZHANG Wen-kang, ex-Minister of Health, signed the “Declaration of Commitment on HIV/AIDS” at the United Nations General Assembly Special Session (UNGASS) and announced China's on-going political commitment.

The Chinese government leaders continued to demonstrate their commitment to AIDS prevention and set examples through personal actions with people affected by the disease. For instance, during World AIDS Day on December 1st, 2006, Premier WEN Jia-bao and Vice-Premier WU Yi invited 17 children orphaned by AIDS and living with HIV, together with doctors and teachers from various provinces as guests of Zhong Nan Hai and to attend the “Our Care — Attention to Children Orphaned by AIDS — Evening Gala Concert”. Premier WEN also took the lead in making donations to children orphaned by AIDS.4

Greater legal and policy support

As the first document in China to address the HIV issue, provisions for “The Management of Monitoring HIV/AIDS” issued in 1987 jointly by various government bodies, played an important role in the monitoring of HIV/AIDS.18 While strategies were initially adjusted, they continually failed to keep up with the rising HIV transmission rates. In response, the Chinese State successively issued “Medium- and Long-Term Plan of HIV/AIDS Prevention and Control in China” in 1998, “China's Action Plan for Containment and Control of HIV/AIDS (2001-2005)” in 2001, and the “Second 5 years Action Plan (2006-2010)” in 2005. The goals of these plans were to specify the direction of HIV control in China in a clear manner. The Regulation on AIDS Prevention and Treatment (Decree No. 457) was issued by the State Council on March 1st, 2006, and is the first legal framework developed in China for a specific disease or epidemic.19 This document provides a legal framework for AIDS initiatives, emphasizing the accountability of governments and Ministries at different levels. It also set out the rights and responsibilities of people living with HIV, ensures the funding of AIDS measures and provides the legal foundations for AIDS policy formulation and its effective implementation.

More funding

Beginning 1996, the Ministry of Finance set up a special fund for HIV/AIDS prevention and control, with an initial contribution of 5 million RMB. Between 1998 and 2000, the contribution increased to 15 million RMB per year. Since 2001, this contribution has further increased to 100 million RMB per year. With the AIDS Prevention and Treatment Regulations initiated in 2006, the implementation of HIV prevention was brought into legal management control.19 To implement this regulation, the Chinese central government increased funding for annual prevention of HIV/AIDS to more than 953 million RMB in 2008 (Figure 3).

Figure 3.
Figure 3.:
National AIDS Program budget from Chinese Central Government.

Infrastructure development

The HIV surveillance system in China is continually being perfected. In 1995, the first general investigation on the HIV epidemic in China was conducted. This investigation included 42 HIV sentinel surveillance sites in 23 provinces for monitoring HIV infection, with four high-risk groups surveyed: those with STDs, drug users, sex workers and long-distance transport drivers.20 The number of HIV sentinel surveillance sites has since increased to 393 by the end of 2006 with nearly 500 sites at the provincial level.4 For the most recent investigation, four additional high-risk groups were added: MSM, pregnant women, clients of female sex workers and tuberculosis patients. In addition, starting 2009, the HIV sentinel surveillance began combining HIV surveillance with risk behavior surveillance. With additional sources from case reports, mass screenings of key target groups, and special epidemiological studies, the sentinel surveillance data have been informative in estimating the number of persons infected with HIV in China.21,22

Testing as entry for prevention and treatment

During the mid-1990s, voluntary counseling and testing (VCT) services were made available in some communities, but they were rarely used even when available. Reluctance to seek HIV testing was probably due to a variety of reasons, such as 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. In recent years, the government has addressed environmental barriers to testing. HIV testing was made freely available in 2003 for the poor. Free HIV testing in VCT stations (4293 as of October 2007) were established nationwide.4 The AIDS regulations have introduced penalties for health units that do not provide free testing on request. In addition, the number of screening laboratories now totals 6066, along with 165 confirmation laboratories.

Scaling-up of prevention and treatment measures

Public education

One important component in HIV/AIDS control is raising awareness of this infection and reducing related stigma surrounding it. Since 2006, the educational establishments, businesses, health providers, customs and border controls, and the media from the governments at the county level and above have been required to promote HIV/AIDS education and social marketing according to the AIDS regulations.19 President HU Jin-tao, Premier WEN Jia-bao and other senior government leaders have publicly visited patients living with HIV/AIDS and shook hands with AIDS patients on World ADIS Days in past years. In addition, many national level mass organizations and civil society groups have been actively involved in HIV work and have provided support for the development and capacity building of community-based groups. Provincial STD/AIDS associations have also been strengthened. By the end of October 2007, STD/AIDS associations have been established and further developed in 18 provinces, while many districts and cities have also been motivated to establish STD/AIDS associations.4

Interventions for sexual contact transmissions

Commercial sex work is illegal in China. Hence, the traditional strategy for controlling HIV transmission through CSWs was raids on suspected sex establishments by public security officials.23 The first intervention program was initiated by the China Center for Disease Control and Prevention in 1996 and 1997, and involved condom use to promote safer sex behaviors to prevent HIV and other STDs among CSWs working at entertainment establishments in Yunnan.24 This was followed by several site trials, which included condom promotion, establishment of STD clinics to provide check-ups, and outreach for health education and counseling. The findings from these trials provided evidence that the interventions were effective and they were used to draft national guidelines for interventions among CSWs in China. The provision of condoms at entertainment establishments is now an official requirement under the AIDS Regulations.19 In 2006, numerous provinces conducted condom use promotion campaigns at entertainment places as well as across relatively large areas. Comprehensive interventions, mainly focused on condom promotion, were launched nationwide.4 The coverage of intervention programs for CSWs and their clients were expanded to all counties by 2007 and had reached 462 357 CSWs by the third quarter of 2007. Thus, intervention coverage for CSWs increased to 38%, up from 26% in 2005. The national behavior surveillance survey data showed that the rate of female sex workers using condoms every time in commercial sex during the last month had increased from 14.7% in 2001 to 41.4% in 2006.4 The rate of CSWs never using condoms decreased from 37.4% in 2001 to 7.5% in 2006.

Among MSM, the Chinese government has strengthened its intervention efforts to prevent transmissions, developed national working protocols and guidelines on HIV prevention and control, and convened national technical workshops on comprehensive HIV prevention interventions since 2005. Various programs were conducted on condom promotion, counseling and testing, peer education, sexually transmitted infection services and follow-up outreach and care services for persons living with HIV. The third quarter 2007 statistics showed that 88 082 MSM were reached by comprehensive HIV prevention interventions, a coverage of around 8.2% of the MSM population.4

Interventions for IDUs and other drug users

The early prevention activities targeted toward IDUs tended to focus on posters outlining the harmful effects of drug use. However, in the late 1990s, the Chinese government changed its attitude towards preventing HIV transmission among IDUs. A pilot needle exchange program was initiated in Yunnan Province and Guangxi Zhuang Autonomous Region in 1999; the findings were used to develop national policy guidelines on the needle exchange program, which was included in the second 5-year plan.25,26 By 2006, a total of 729 needle exchange stations were established in 204 counties or districts in 17 provinces and about 49 108 IDUs had joined clean needle exchange programs by the third quarter of 2007. However, interventions must be continuously strengthened among IDUs, especially in cities with higher HIV prevalence rates.27

At the same time, methadone maintenance-treatment (MMT) programs were launched by the Chinese government in 2004 to treat drug addictions and subsequently reduce risk behaviors. With a pilot study initiated in 2004 on eight methadone maintenance clinics in five provinces, the number of clinics increased to 558 sites by the end of 2008.28-30 Combined with cutting the consumption of heroin by nearly 16.5 tonnes, more than 170 000 drug addicts have undergone methadone therapy to discontinue their addictions since 2004.

By the end of October 2007, 88 313 drug users had joined the MMT treatment program.4 Among 51 758 participants who are now on treatment, the annual retention rate is 64.5%. The clinics also provide free HIV testing and counseling service on a regular basis to all individuals who joined the MMT program. An evaluation of the first eight MMT clinics found positive changes in the rate of injecting drug use, drug-related illegal offences, employment opportunities and family relations.31 With the promotion of methadone maintenance clinics and implementation of needle exchange programs, the pace of HIV/AIDS prevalence among drug users has slowed in recent years. Since 2004, China has expanded its harm reduction program rapidly and that has also slowed the spread of HIV among drug users.32

Prevention of mother-to-child transmissions (MTCT)

A feasibility trial for preventing MTCT was piloted in late 2002.33 Mothers who tested HIV positive were offered counseling, the option of an abortion or antiretroviral therapy to reduce the likelihood of MTCT. On the basis of this pilot program, the prevention program was expanded to eight counties in five provinces. From the experiences of technicians who worked in the local Maternal and Child Health Clinics and had implemented the intervention measures, national guidelines were developed to guide the prevention of MTCT in the country. Services are being scaled up to reach at least 90% of infected pregnant women by 2010.19

Scaling-up of treatment services for HIV-positives

Under the “Four Free and One Care” policy in 2003, the National Free ART Treatment Program was established by making ART freely available to all through the Chinese health care system.34 The National HIV/AIDS Clinical Taskforce took the lead in establishing the program, and set up the National Free ART Database to monitor it. Established in late 2004, it includes data on current patients and those treated before 2004. By the end of October 2007, the provision of ART was expanded to 1190 counties in 31 provinces, autonomous regions and municipalities. A 5-year outcome study of the National Free ART Treatment Program showed that 52 191 patients aged 18 and above had commenced treatment through August 2008.35 Mortality was greatest during the first 3 months of treatment (22.6 deaths/100 person-years) but decreased to a steady rate of 4-5 deaths/100 person-years after 6 months. This rate was maintained over the subsequent 4.5 years. Overall, treatment failed for 25% of patients (12.0 treatment failures/100 person-years), with the cumulative treatment failure rate increasing to 50% after five years. Challenges for the program include integration of drug treatment services with ART, an under-resourced health care system, co-infections, stigma, discrimination, drug resistance, and procurement of second-line ART. The merging of national treatment and care, epidemiologic, and drug resistance databases will be critical for a better understanding of the epidemic, for earlier identification of patients requiring ART, and for improved patient follow-up.36

Quantitatively measuring policy implementation

The China AIDS Monitoring and Evaluation (M&E) Protocol sets out principles and measures, specifies content and indicators, and provides institutional and management mechanisms. A national M&E expert team was formed and a national technical support facility was appointed. Clear requirements for the local authorities in establishing specific units and carrying out M&E activities were also compiled. During 2007, the government undertook training to strengthen M&E capacity at provincial levels and improved coordination of M&E activities in local areas.4 Various forms of monitoring, including joint cross-sector, comprehensive technical and special missions in particular aspects of program implementation were conducted for specific aspects of the program at different levels. These missions assisted in improving the efficiency of monitoring work to facilitate the AIDS response.

CHALLENGES

Manpower

Given the population of China, there is a paucity of trained manpower at all levels, from central to villages and communities. Human resource capacity is a major constraint on China's ability to deliver HIV prevention and care. Many rural areas, where most of China's HIV-positive population resides, do not have the capacity to monitor patient CD4+ cell counts and viral loads. In some instances, the physical infrastructure exists, but staff may not have the skills to use it. Many health workers and educators have poor knowledge of HIV. Even many of those willing to work in rural areas do not have formal medical qualifications, thus limiting their ability to understand the complexities of treating HIV patients.37 Within the rural areas themselves, there are few adequately trained technical and management personnel at all levels and across all sectors.

Stigma

Stigma and discrimination against HIV-positive persons remain widespread in some communities and work places, including among health-care workers.38-40 The involvement of people affected by AIDS in the design and implementation of intervention messages remains weak and needs to be strengthened for more effective outcomes.

In particular, the latest estimates indicate that 11% of the approximately 700 000 HIV infected persons were contaminated through MSM transmission, an increase from 7.3% in 2005.4,9 Because this population is being stigmatized and difficult to be accessed in terms of conducting serologic surveys or prevention outreach, more effective intervention methods are needed to control the HIV epidemic among MSM in China.

Complexity of HIV/AIDS

The management and evaluation of prevention and care programs in China is a very large challenge given the enormous size of the country; the variation in patterns of HIV infection among provinces, municipalities, and autonomous regions; and the concentration of HIV-infected persons in rural areas. In addition, potentially large numbers of those who are HIV-infected have not been tested, perhaps as high as 94%.5 This makes successful interventions and treatments difficult to reduce HIV transmissions.

CONCLUSION

After a slow start and reluctance to recognize the existence of risk activities in its population and of the HIV epidemic, the Chinese government has demonstrated its commitment and willingness to take action to control HIV/AIDS. China has responded by taking bold steps to control the epidemic, using scientifically validated strategies. 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. The country now faces the challenge of scaling up these programs and of convincing all levels of government to implement these innovative strategies and policies. However, with strong government support and close collaboration between health workers and law enforcement agencies, China is well on its way towards achieving its goals. This vigorous response, incorporating research findings into policy formulation, can be informative to other countries that face similar challenges in responding to the HIV/AIDS epidemic.

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Keywords:

China; HIV/AIDS; achievements; challenges

© 2009 Chinese Medical Association