HIV in China

Chin Med J 2008;121(13):1230-1236 1230 Review article HIV/AIDS epidemiology and prevention in China SHENG Lei and CAO Wu-kui Keywords: acquired immunodeficiency syndrome; China; disease outbreaks; prevention and control; public policy Objective To review HIV/AIDS epidemic history, current situation and prevention policy in China. Data sources Information included in this article was identified by searching PUBMED (1997–2006) online resources using the key terms “HIV/AIDS”, “epidemic”, “prevention”, and “China”. Study selection Original milestone articles and critical reviews written by major pioneer investigators of the field were selected. Results The key issues related to the HIV/AIDS epidemic situation in China and Chinese government prevention policy were summarized. HIV/AIDS epidemic groups and trends for HIV transmission were discussed. Conclusion In January 2006, 650 000 people were estimated to be living with HIV in China. The overall HIV/AIDS epidemic is at a low level (0.05%) and concentrated in several at risk populations. However, the data show that new cases of HIV infection are growing every year and spreading from at risk populations to the general population. Premier WEN Jia-bao announced the “Four frees and one care” policy and the Chinese government has developed a series of programs with strong policy measures to stop the spread of HIV/AIDS in China. Chin Med J 2008;121(13):1230-1236 hina is a huge country with multicultural and multiethnic characteristics accompanied by wide geographic and socio-demographic variations. China’s large and ethnically diverse population, its geographic expanse, rapid economic growth, institutional transition from a planned to an open economy, and the evolution of social norms, have all shaped the growing HIV/AIDS epidemic. In 2006 there were 650 000 people living with HIV in China as estimated by the WHO, UNAIDS, and the Chinese government. The overall HIV/AIDS epidemic is at a low level (0.05%) and concentrated in several at risk populations, although new cases of HIV infection are growing every year.1 HIV EPIDEMIC HISTORY IN CHINA Since the USA reported the first case in 1981, HIV has become a worldwide epidemic. AIDS was first reported in Beijing, China, in 1985. Since then the HIV epidemic has become more visible in China. The cases reported are increasing every year and have spread throughout the country.1 Four phases of the HIV epidemic in China First phase (1985–1988) was marked by a small number of AIDS cases in coastal cities. The cases were mainly foreigners or Chinese traveling overseas. Four hemophiliac patients infected with HIV through imported factor VIII were reported in Zhejiang Province.2 Second phase (1989–1993) began in October 1989 with the identification of HIV infection in 146 drug users in southwestern Yunnan Province. This was the first sign of a local prevalence and isolated outbreak. The total number of infected people at the end of 1989 was reported as 153 Chinese and 41 foreigners.2 Third phase (1994–2000): In late 1994, HIV transmission spread beyond Yunnan. A considerable number of cases of HIV infection were reported among drug users and commercial plasma donors from various regions. From the mid-1990s, HIV has spread all over China and all modes of transmission were reported. The national figures for HIV infection quickly grew. By August 1996, official statistics had reported 4500 cases of HIV infection and 130 cases of AIDS. By 1998, HIV infection had been reported in all 31 provinces, regions, and municipalities.3 Fourth phase (2001–): The year 2001 was the start of the fourth phase of the AIDS epidemic in China. It is the stage when a number of key events took place which suggested that the silence surrounding HIV in China was beginning to end. These events include: (1) In June 2001, the “China Plan of Action to Contain, Prevent and Control HIV/AIDS” was published. The plan stated that blood for clinical use would have to undergo complete HIV testing and should be provided by non-profit blood centers. (2) In August 2001, the Chinese government published estimates suggesting that there were 600 000 to 800 000 people living with HIV/AIDS. Most of these infections were caused by contaminated blood. (3) In 2003, AIDS cases cumulatively reported in China were 45 092 with 1800 deaths. The national estimate of the number of people living with HIV/AIDS at the end of C Tianjin Infectious Disease Hospital, Tianjin 300192, China (Sheng L and Cao WK) Correspondence to: Dr. SHENG Lei, Tianjin Infectious Disease Hospital, Tianjin 300192, China (Tel: 86-22-27468235. Email: tjshenglei@yahoo.com.cn) Chinese Medical Journal 2008; 121(13):1230-1236 1231 2003 was 840 000 (650 000–1 020 000), with a prevalence rate in the general population of 0.07% (0.05%–0.08%). The figure made China the 2nd highest country in Asia and 14th in the world.4 (4) The 2003 Joint Assessment Report concluded that in 1985, when the first HIV cases were diagnosed, national HIV prevalence remained low but clusters of high prevalence existed, both geographically and among specific sub-groups. There were indications that the disease was spreading from high incidence groups to the general population.5 (5) “Diagnostic Criteria and Principles of Management of HIV/AIDS” was amended by the Chinese government in 2003. (6) In January 2006, the Chinese government along with WHO and UNAIDS estimated that 650 000 people were living with HIV in China (range 540 000–760 000), including about 75 000 AIDS patients.6 The infections remain concentrated among injecting drug users (IDUs), sex workers and their clients, and homosexual men. The new estimates are based on a much wider range of surveillance data, as well as mass screening of former plasma donors (FPDs), made at the prefecture level. Limited data from high prevalence provincial surveillance sites led to past estimates that now seem too high. The figure of 650 000 is lower than previously published in 2003. It does not mean that HIV is now under control in China but that estimates have been lowered due to improved methods of estimation and better data. The data from the national sentinel surveillance system shows that the HIV epidemic in China is still growing. During 2005, there were around 70 000 new HIV infections (range 60 000–80 000). Between 20 000 and 30 000 people were estimated to have died of HIV in 2005. New infections continue to outstrip deaths.6 (7) “Regulations on AIDS Prevention and Treatment” adopted at the 122nd Executive Meeting of the State Council on January 18, 2006 were hereby promulgated and should be effective as of March 1, 2006. HIV EPIDEMIC GROUPS HIV in China is concentrated among populations engaging in high risk behavior, such as injecting drug users, former plasma donors, sex workers and their clients, and men who have sex with men (MSM).7 Injecting drug users (IDUs) Injecting drug use has been the dominant route for HIV infection in China.8 Currently, there are one million drug users in China. Sixty-one percent are injecting and over 50% share needles. They are mainly concentrated in Yunnan, Xinjiang, Guangxi, Guangdong, Guizhou, Sichuan and Hunan provinces. HIV/AIDS transmission through injecting drug use is associated with 43.9% of HIV infections in China.4 The average HIV prevalence rates among IDUs increased from 0.04% in 1995 to 5.9% in 2002, and even reached 20%–30% in some areas in 2001. Another risk of factor is the high turnover of sexual partners among IDUs leading to further spread of HIV in China. Behavioral surveillance shows that IDUs are also more likely to buy and sell sex.7,8 Former plasma donors (FPDs) A shortage of blood products in China led to a large market for illegal commercial plasma/blood collections in the 1980s and early 1990s. Hundreds of commercial plasma collection centers were established in central and eastern China. The paid donors were generally farmers from poorer areas. Plasma donation was much more popular than whole blood donation. Commercial plasma donation with unhygienic re-fusion of red blood cells (RBC) was common in rural communities in the early 1990s.8 Donation procedures reused unsterilized equipment that allowed blood-borne infections to spread rapidly through the local donor population. Since 1995, the problem of HIV spread among FPDs has become apparent. The outbreak of HIV/AIDS among FPDs was mainly in Henan, Hebei, Hubei, Anhui, Shanxi and Jilin provinces. The rate of FPDs infected with HIV was between 10% (the lowest area) and 60% (the highest area).9 By 2003, 24.1% of cumulatively reported HIV/AIDS cases in China had been attributable to commercial plasma/blood donation.4 The 2003 estimated figure was 199 000 FPDs living with HIV. In 2005, the estimated numbers of infected former plasma/blood donors fell from 199 000 to 55 000.6 This group is now reaching a stage of high mortality. It is estimated that there were at least 10 000 deaths in 2005 alone. Commercial sex workers HIV infection among heterosexual groups are rising rapidly because of flourishing commercial sex services, despite China’s abolition of brothels in 1955. The national estimate of the number of Commercial sex workers (CSWs) in 2001 was about 4 million whose rate of infection with HIV was above 10%. Large numbers of CSWs in coastal area and big cities doing transient sex work is now common in hotels, pubs, hairdressing salons, bathing centers, massage parlors, song bars and ballrooms, or from the streets. In 2003, heterosexual transmission accounted for 8.1% of cumulative reported HIV/AIDS cases in China.9 Along with the growth of commercial sex and continued low rate of condom use, sexually transmitted diseases (STDs) have increased sharply.10 CSWs have an important bridging role in transmitting HIV from core groups to the general population.8 Men who have sex with men There are up to 8 million MSM with a 1%–4% rate of HIV infection in China. Unprotected sexual activities, including group sex, anal sex, casual sex and commercial sex are prevalent among Chinese MSM.11 While homosexual activities are not illegal in China, they are not considered socially acceptable. Homosexual or bisexual men still hide their sexual orientation and often marry women. Married MSM may acquire HIV from their high risk male sexual partner and transmit it to their wives.12 Cases of MSM infected with HIV account for 11.1% of accumulated cases that were reported in 2003 in China.4 MSM has become a rapidly growing group in the Chin Med J 2008;121(13):1230-1236 1232 HIV epidemic in China and they are at high risk of HIV infection and contribute to the spread of HIV to women and the general population.11,13 In addition, groups of male commercial sex workers have appeared in large cities. A survey show that 38% of MSM investigated in four cities in China had paid for sex.2 POTENTIAL FOR HIV TRANSMISSION HIV transmission in families Studies in China have confirmed that HIV transmission is occurring at the family level. IDUs, CSWs, FPDs and married MSM may transmit HIV to their spouses and children.14 Two recent studies among FPDs showed that the rate of HIV sexual transmission among discordant couples is 11% and the rate of mother to child transmission (MTCT) is 38%.15 It is proven by a group of orphans infected with HIV left by FPDs, that the spread of HIV in China has reached the stage of MTCT. Since the first case of MTCT was reported in 1995, the proportion in MTCT has increased from 0.1% of the total reported HIV-positive cases in 1997 to 0.4% in 2002. Although pregnant women and children have been at low risk of MTCT of HIV, an upward trend has been reported since 2005. HIV transmission through migration China’s first case of HIV was a foreign traveler. With the country’s open policy, China now has several million international travelers visiting each year, and also large numbers of Chinese travelers going abroad. There is also a huge internal migrant population in China. There are currently about 120 million migrant workers in China, of whom about half are registered, nonpermanent residents working in the fastest developing regions. Migrants are largely young and sexually active. Both male and female migrants are likely to be linked with commercial sex when away from home. Data show that migrants also have a higher proportion of IDUs and FPDs. Floating populations are the most difficult to reach with preventive health education and they tend to be deprived of access to health care. China’s internal migrant labor population may become the most vulnerable to HIV infection.16 Migrants may spread HIV/AIDS between rural and urban areas as well as from HIV concentrated regions to low prevalence regions. Migration of people is an important factor that may accelerate the HIV epidemic and has been the major factor in turning HIV/AIDS into a worldwide epidemic. HIV transmission in hospitals HIV may be transmitted through medical equipment and instruments, or via blood products in hospital. Unsafe injections still occur in local clinics especially in rural areas. On the other hand, doctors, nurses and technicians working at laboratories may be infected with HIV after exposure to HIV-positive blood during their work.17 HIV transmission in universities A cross-sectional survey of 1326 students between the ages of 17 to 28 was conducted in 2002. Results indicated that 14% of Chinese university students are sexually active and risk behaviours tend to increase with age. Additionally, 24% of the students considered themselves to be at a moderate to very high risk of contracting HIV and 40% of sexually active students never used condoms.18 In addition, the university students come from different areas in China, or other countries, which may lead to the spread of the HIV epidemic. HIV PREVENTION IN CHINA Two decades have passed since the first HIV/AIDS case was described in 1981. Cumulatively, over 20 million people have unfortunately lost their lives, more than 40 million people are now living with HIV, and most of them are from developing countries. China, as the biggest developing country, has an impact on the epidemic of HIV/AIDS. From the first case of AIDS diagnosed in Mainland China in 1985, the epidemic has spread at an alarming rate.19 China, a vast country of 1.3 billion people, faces tremendous logistical challenges in combating the HIV/AIDS epidemic. Despite a downward revision in 2005 (650 000) estimates from 2003 (840 000) HIV/AIDS estimates, China still faces a growing epidemic. WHO warned that, if there were no effective preventive measures adopted, that the number of HIV/AIDS cases would reach 10 million in China by 2010.19 The early cases of HIV/AIDS in China were mostly foreign nationals. The Chinese government’s response to early cases of HIV/AIDS was to stop and prevent HIV from entering China. However, the policy was not effective.20 Initially, the Chinese government’s AIDS policy amounted to restricting entry into China of people infected with HIV, as well as initiating measures that reinforced the illegality of homosexuality and drug use. As the epidemic continues to spread throughout China the government has taken a much more active role in HIV prevention, including creating policies to care for the carriers of HIV. At the center of China’s HIV/AIDS policy is the China CARES program (China Comprehensive AIDS Response). China CARES originally concentrated on AIDS patients who were infected with HIV due to unsafe blood collection, particularly in Henan Province. Recently, the China CARES program has been expanded to respond to a more diverse patient group and has increased its focus on health education and comprehensive treatment. Although the government was slow to respond to the epidemic in the late 20th century, it has made a vigorous response since the early 21st century. Components of that response include implementation and evaluation of harm reduction programs for IDUs, education to increase knowledge and reduce stigma, treatment and social support for rural and poor HIV/AIDS patients, widespread testing, and increased funding for HIV/AIDS programs.21 Chinese Medical Journal 2008; 121(13):1230-1236 1233 To monitor the effectiveness of recent policy changes, the government is conducting a mid-term evaluation of China’s Medium and Long Term Program for the Prevention of AIDS (1998). This program aims to limit HIV infections to 1.5 million by 2010. The program’s focus includes: ensuring safe blood collection and blood use practices, implementing health education, and providing care for HIV/AIDS patients and their families.22 The mid-term evaluation will enable the government to assess which prevention and treatment strategies are effective and identify those that need to be altered. Blood donation policy Unsafe blood collection is the cause of many AIDS cases in China. The Chinese government has cracked down on blood collection centers in an attempt to completely eradicate HIV infections due to unsafe blood collection. In 1995, the problem of HIV spreading among FPDs first appeared. The Chinese government took strong legal action to prevent further spread of HIV infection by closing commercial plasma collection centers and issuing new regulations for blood/plasma donations. In 1998, the “Law on Blood Donation” became effective nationwide. It requires HIV screening for all blood donations and more than 85% of blood to be provided by non-profit blood centers for clinical use.22 There have been major achievements in ensuring that blood is collected safely. Currently, volunteers donate 88% of the total blood collection, up from 22% in 1998. In 2002, the Chinese government updated its “Action Plan” to reduce HIV infections to 1.5 million by 2010. The new version included measures for blood used for clinical purposes to be run though HIV screening, as well as demanding that 85% of blood be donated by non-profit blood centers, with the rest coming from authorized hospitals for their own use.22 Starting from May 2004, the government has sponsored a major nationwide campaign against unsafe blood collection, in an attempt to shut down all illegal blood collection stations. In May, two stations were shut down, demonstrating the need for this kind of campaign. The government has also passed laws to ensure that blood is donated, not sold, and 26 provinces, municipalities and regions have passed local regulations in accordance with the laws. Funding for blood safety has increased greatly in the past five years. In response to the high number HIV infections through contaminated blood supplies and illegal blood donation, billions of RMB have been dedicated to improving blood centers nationwide. Blood center workers are also receiving more advanced training. In 2004, the Shanghai Blood Administration Office implemented an identity card checking system to increase the safety of the blood supply. This crackdown, along with many others nationwide, demonstrated the commitment of the Chinese government to stopping the spread of HIV. Methadone maintenance treatment and needle exchange programs Methadone maintenance clinics and needle exchange programs (NEP) are now being implemented in China as a response to the rapid increase in prevalence of HIV/AIDS over the past 10–15 years. It is worth noting that in prior years methadone was available only for short-term detoxification from opiates and for research purposes. To reduce the risk of HIV infection among