BEIJING—Encouraged by last month’s news that AIDS mortality has plummeted in China, authorities here are embarking on a new 5-year plan for tackling the epidemic that includes ambitious targets for case detection and access to treatment. But further gains are jeopardized, critics warn, by rampant discrimination against HIV-infected individuals and the entrenched stigma of homosexuality in China.
“HIV/AIDS prevention is not just a clinical matter,” says Joseph Lau, a public health expert at Chinese University of Hong Kong. “There are serious social and culture barriers to overcome to ultimately win the battle against the disease.”
By the end of 2010, China had recorded 379,348 cases of HIV infection, including 138,288 people who had developed AIDS, and 72,616 deaths, according to Wu Zunyou, director of the National Center for AIDS/STDControl and Prevention of the Chinese Center for Disease Control and Prevention (CDC) here. After years of virtually ignoring the epidemic, China introduced antiretroviral therapy to treat HIV-infected people in 2002. That move made a huge difference: In The Lancet Infectious Diseases on 19 May, Chinese CDC researchers reported that AIDS mortality in China declined 64% between 2002 and 2009. Mortality rose slightly last year.
But for thousands of Chinese, interventions are coming too late, or not at all. CDC estimates that there are 740,000 HIV-infected people—twice the reported number. ManyAIDS patients in China are gravely ill by the time they are fi rst tested for HIV, says Hao Yang, deputy director of disease prevention and control at China’s health ministry. In 2010, a quarter of those who tested positive had already developed AIDS, and nearly half of the partners of HIV-infected people were infected; among fatalities, 82.4% died before getting treated. “Early detection remains the biggest challenge,” Wu says.
In the new 5-year action plan, China aims to reduce new infections by 25% and the fatality rate by 30% by 2015, Wu says. To achieve those targets, the government will expand detection programs, aiming to diagnose 75,000 cases this year, up 16.6% from 2010, and put more than 40,000 more people on treatment; by the end of last year, 108,800 people were on antiretroviral drugs. Hospitals in regions with high infection rates intend toimpose mandatory HIV testing for patients and for high-risk populations, including sex workers, injecting drug users, and men who have sex with men (MSM).
Many experts warn that the strategy is likely to backfi re. “Mandatory HIV testing may pose threats to individuals’ rights,” says Zhang Konglai, an epidemiologist here at the Institute of Basic Medical Sciences of the ChineseAcademy of Medical Sciences (CAMS).
“There are reasons why people don’t want to go and get tested.” The chief fear is the black mark that HIV infection represents in Chinese society. “The consequence can be disastrous for people with HIV and their families if their HIV status becomes known,” says Guy Taylor, an advocacy expert in the Beijing offi ce of the Joint United Nations Programme on HIV/AIDS (UNAIDS).
China’s top leaders have sought to ease the stigma. On World AIDS Day, state media have given prominent coverage to Chinese President Hu Jintao’s visits with AIDS patients. Hoping to reach out to more HIV-infected people, CDC has set up a network of some 9500 clinics that offer free and voluntary HIV/AIDS counseling and testing over the past decade.
However, few people avail themselves of these services. Many fear that a positive HIV status will not be kept confi dential, Taylor says. According to a 2009 UNAIDS survey, nearly a third of HIV-infected individuals reported a breach of confi dentiality by employers, friends, family members, and health care workers. The survey revealed that 12% of infected individuals had been denied treatment because of their HIV status, 7% had been forced to move home, and over threequarters said that family members had experienced discrimination. More than one-third claimed that they had been refused a job, had been denied a promotion, or had their job duties changed as a result of their HIV status—despite a 2007 national law that guarantees HIV carriers the right to work. Undermining that law are national regulations that prohibit people with HIV/AIDS from working in the civil service, or in hotels, cafes, and beauty salons, for example. Last August, a 22-year-old college graduate sued Anhui Province education bureau for rejecting his job application after he tested positive for HIV in a mandatory civil service blood test. He lost his case and the appeal. “This has sent a very bad signal and will encourage more employers to turn down people with HIV/AIDS,” says Zhai Xiaomei, director of CAMS’s Center for Bioethics here. With livelihoods at stake, few HIV-infected individuals are likely to submit to testing until they have full-blown AIDS.
In the meantime, HIV is spreading rapidly among MSM, who are estimated to account for a quarter of the infected population. In a 2009 survey of 61 cities in China, the infection rate among MSM was around 5%—100 times the reported national average—and up to 18% in places. “It’s just the tip of the iceberg. The infection rate may be much higher and is rising rapidly,” says An Ran, director of Shaanxi Tongkang Working Group, a nongovernmental organization (NGO) in Xi’an that offers voluntary HIV/AIDS testing and counseling. Recent HIV testing in Xi’an bathhouses, a popular venue for MSM to meet, revealed infection rates as high as 50%. In Sichuan Province, Lau and his colleagues found that the HIV infection rate among MSM had risen from 1% in 2005 to 14% this year in the capital, Chengdu, and from 15% a couple of years ago to 23% in Zigong. There are an estimated 14 million or more MSM nationwide. According to Wu, 212,509 were tested for HIV in 2010; this year’s target is 236,600.
Complicating efforts to contain HIV’s spread, roughly a third of MSM in China are married, and half have both male and female sexual partners, says Zhang Beichuan, an AIDS expert at Qingdao University. “This is putting a large number of women at risk,” he says. “But HIV prevention targeting those women is an untouched subject in China.” Another impediment to stemming HIV is the harsh treatment of injecting drug users.
By the end of 2010, China had over 1 million heroin users, says Li Jianhua of the Yunnan Institute for Drug Abuse in Kunming. China has made inroads in this population. Some 700 methadone clinics and more than 1000 needle-exchange sites around the country have reduced HIV infection by half in the past decade among tens of thousands of visitors. But many drug users “stay away from such services for fear of getting arrested,” Li says. In China, heroin users are detained in prisonlike rehabilitation centers for up to 3 years.
In these centers, which currently house some 230,000 drug users, detainees must submit to mandatory HIV tests, but often they are not told the results until just before release, Li says. With rare exceptions, he says, inmates do not receive counseling or treatment. With few signs that stigmatization is relenting, China must rely on NGOs to help reach out to HIV-infected people. To do so, Lau says, the government must ease restrictions on NGOs, which can register only if they are affi liated with a government agency; many operate without legal status or a bank account.Organizations that campaign for safe sex and public acceptance of HIV/AIDS and homosexuality report that they are often harassed by the police.
Last month, a simmering controversy over China’s reluctance to support genuine grassroots NGOs hit a boiling point when the Global Fund to Fight AIDS, Tuberculosis and Malaria halted grant payments to the country, citing concerns such as misuse of funds and corruption. In the current HIV/AIDS program, a 6-year, $500 million scheme launched last year, China had pledged to allocate 20% of the fi rst year’s budget to NGOs and gradually raise that to about 35%. “But most of the funding has gone to ‘official NGOs’ created and controlled by the government,” says Jia Ping, director of China Global Fund Watch, an NGO here. In response, the health ministry plans to overhaul its HIV/AIDS program; Minister Chen Zhu has vowed to correct spending irregularities and punish culprits. With an estimated 50 million people at risk of HIV infection, China is at a critical stage in controlling the AIDS epidemic, Taylor says. “What we need is the normalization of HIV testing,” he says. “This is unlikely to happen without greater involvement of civil society … or properly addressing the issues of stigma and discrimination.” –JANE QIU
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