AIDS in China: Anatomy of an epidemic
Jul 28th 2005 | RUILI From The Economist print edition

It is not too late to avert a national catastrophe

SURELY China does not face a general AIDS epidemic?
The government says that only 0.07% of the general
population is infected with HIV, the virus that causes
AIDS, and, unlike some other governments' figures,
this one may be an overestimate. The World Health
Organisation (WHO) would prefer to quote a range of
0.05-0.08%. Moreover, large areas of the country have
relatively few cases of HIV: in only three of China's
31 provinces, autonomous regions and municipalities
are more than 10,000 people infected. Even so, China
does have an AIDS epidemic and, though it may not yet
be a catastrophe on a national scale, it has the
potential to become one.

Several features of this epidemic are already serious
enough to cause grave concern. First, it has spread to
every province (see map) and half the counties within
them. Second, the number of reported cases is growing
(chart 1, with map) and, since 85% of those infected
do not know they are HIV-positive, the growth will
continue. Third, among certain groups, the infection
is present in alarming proportions (chart 2). Fourth,
even a low prevalence rate, such as the WHO's
bottom-of-the-range 0.05%, means 650,000 infections;
the government's rate translates into 840,000. Either
means personal tragedy on a vast scale. This points to
the fifth reason for concern: in a country as big as
China, an AIDS explosion would have economic,
political and social consequences for the entire
world.

Such an explosion, however, is far from inevitable,
thanks mainly, and paradoxically, to another nasty
disease, SARS. For 15 years or more after China
announced its first AIDS-related death in 1985, the
country's leaders were in denial about HIV. Few cases
were reported, and homosexuality and promiscuity, the
two agents by which this “western” affliction was
presumed to spread, were said to be limited in China.
Then, in November 2002, came the outbreak of severe
acute respiratory syndrome, SARS, in Guangdong
province. By the time it had been contained, China's
leaders had come to realise just how vulnerable the
country was to such a plague. SARS was not like a
nasty new strain of flu that carried off great
quantities of sickly people and then was gone. It was
a deadly and highly contagious disease that threatened
to paralyse China and did indeed bring Beijing to a
standstill, with even the leaders' Zhongnanhai
compound being quarantined. The economic threat posed
by such diseases was clear, and suddenly AIDS too
looked potent.

By that time, however, the disease was well
established among two large groups. One was chiefly
made up of peasants in central China, people so poor
that in the late 1980s and early 1990s they readily
and regularly sold their blood to dealers known as
bloodheads. The trade was vastly profitable in a
country with a huge need for blood and no tradition of
giving it.

In some places, almost everyone was bringing blood to
the market; collection points were often set up in
fields. But the onset of anaemia soon put a limit on
the amount that sellers could provide. Not for long:
by 1993 the bloodheads realised that they could both
keep anaemia at bay and harvest an almost perpetual
crop if they took only plasma. To cut costs, they
mixed together the blood of all the peasants of the
same group before extracting the plasma. They then
separated the plasma and transfused the remaining
blood corpuscles back to the peasants. No surer way of
spreading hepatitis-B, hepatitis-C, malaria and HIV
could be imagined, especially as many blood-sellers
went from one collection point to the next.

More people in China have contracted AIDS through the
sale of blood—the equipment used was usually
unsterilised—than through any other means. In Henan
province alone, according to a recent report, about
300,000 people became infected, mostly in 1994-96.
Roughly 170,000 people contracted HIV through the sale
of plasma, the other 130,000 through the use of dirty
syringes in the collection of whole blood, or by
getting it through transfusion.

The sale of blood was made illegal in 1998 and steps
have now been taken to improve the entire
blood-donation service and to reduce the number of
collection organisations—crucial to establishing
quality control—from over 600 to about 350. But 350 is
still far too many, and they remain commercial
ventures, belonging to hospitals or laboratories, even
though no one is meant to be paid for giving blood
(some sales probably continue). Moreover, no one has
ever been brought to book for what is widely
acknowledged to be a national scandal. It remains a
matter of great political sensitivity.

Drugs and sex on the border
As a means of transmitting HIV, however, commercial
blood-gathering has been overtaken by dirty needles
among drug-takers (chart 3). The resulting outbreak
has been growing for years, especially in the southern
provinces that abut the drug-producing countries of
Myanmar, Laos and Vietnam. By 1993, one of these,
Yunnan, had more AIDS cases than any other part of
China. Hence the decision that same year to open the
country's first AIDS hospital there, in Ruili, the
most AIDS-ridden town in the province.
___________

The World Health Organisation published a report on
AIDS in China. The Global Fund has information about
its fight against AIDS. The Clinton Foundation has an
initiative to combat the disease. See also the
Mangrove Support Group.

Despite a large general hospital in the middle of the
town, and on the other side of the road an AIDS centre
for women and children started in 2001 by Britain's
Save the Children charity, there is no sign of an AIDS
hospital in Ruili today. The need, however, is greater
than ever.

Ruili stands on the border with Myanmar, which
provides a constant supply of drugs. Also pouring over
the border are the Burmese prostitutes who work in the
salons and massage parlours close to the lorry park by
the crossing-point. These girls are poor, and cheap;
some earn as little as 5 yuan (about 60 cents) per
customer. Many carry sexually transmitted diseases,
and some are HIV-positive. They may have read the sign
by the frontier post that shows a tightly furled
condom, held in a delicate female hand, with a message
recommending its use for health, happiness and
protection against AIDS, but the girls are often too
poor, or too intimidated, to refuse a client, often a
truck-driver, who insists on unprotected sex.

In Thailand, which has also been threatened by AIDS,
the brothels proved to be a useful element in the
successful fight to avert a general epidemic. Most
brothel-owners readily agreed to the use of condoms,
as did the women working in them. To an extent, Ruili
offers hope of a Thai outcome. The Chinese prostitutes
in the town—many of them members of minority groups
such as the Dai, Jingpo, De'An and Lisu, who make up
about 60% of the local population—are likely to work
for madams who look after their girls and favour
condoms. And though prostitution is illegal, despite
its undisguised practice all over the country, the
madams do not object to efforts to inform their girls
and provide them with condoms.

Moreover, Chinese prostitutes are unusual in that most
of them are free agents. They are typically village
girls who, like so many in today's China, want to make
money fast. With little education, they see
prostitution as a way to do this, before they settle
down, marry and have children, perhaps with a small
business. Uneducated they may be, but they are
independent enough to take advantage of both advice
and prophylactics, if available.

Burmese prostitutes are different. They are much less
likely to be girls with a business plan, much more
likely to be those who have fallen on hard times and
are therefore vulnerable to the exploitation of pimps.
In China, they are also, as foreigners, ineligible for
free treatment. Once infected, they can, of course,
pass on their infection to anyone.

Drug-addiction is a further complication, and one that
may afflict any of Ruili's prostitutes. The Dai have
been taking opium for years, and for some Dai men
drug-taking is seen as a rite of passage. Among other
Chinese, to be visibly under the influence of drugs
may be a sign of affluence. So drugs are popular on
both sides of the border. Needles, though, are not—and
one shot with a dirty needle is enough to ensure
infection.

Ruili, you may say, is untypical, both because of its
palm-fringed boulevards, Buddhist temple and Christian
church and because of its louche atmosphere, minority
traditions and proximity to Myanmar. Yet if its drugs
and prostitutes also make it untypical, that is only
because they are a bit more obviously available here
than in other parts of China. A plausible estimate
puts the number of Chinese drug-takers at over 1m, and
prostitution is now conspicuously practised in every
city, close to almost every hotel, every building site
and even every mine, where tented bordellos appear as
soon as the first sod is turned.

The Chinese, it should be said, are probably no more
promiscuous than any other nation. Indeed, their
culture has long frowned on extra-marital sex, and so
has the Communist Party, so much so in the 1980s that
all signs of commercial vice were ruthlessly
suppressed, with the happy result that sexually
transmitted diseases were all but stamped out. Now,
however, they are back, and flourishing in particular
among the members of another new phenomenon—the
“floating” population of 120m-140m people who have
left a poverty-stricken existence in the countryside
for menial jobs in the cities.

Some say most building workers are too tired and too
poor to patronise prostitutes. But most of those who
make it their business to worry about AIDS in China
see these migrants as a terrifying transmission belt
for HIV. Removed from their families for most of the
year, they occasionally go home for a holiday, perhaps
bringing an infection with them. Meanwhile, the
400,000 truckers who pass through Ruili each year are
also plying back and forth, some taking AIDS to a wife
or girlfriend.

The huge task now in China is to contain the two main
AIDS outbreaks. The blood-borne one is waning, though
it leaves a terrible legacy of infected people. The
drug-driven one is growing, and threatens to spread
through heterosexual sex. Encouragingly, the
SARS-struck government has changed its attitude
dramatically. Whereas a few years ago a woman carrying
a condom was liable to be arrested as a prostitute,
condoms are now officially promoted and even, in
theory, given away. In Yunnan, hotels have to provide
them (for a price) in their guestrooms.

Treatment is also improving. Since December 2003, the
“four frees and one care” policy has been in force.
This brings free anti-retroviral drugs to all infected
people in the countryside and to poor people in towns;
free advice and testing for those who want it; free
drugs for infected pregnant women, to prevent mothers
infecting their babies during childbirth; free
schooling for AIDS orphans; and financial help for the
families of people affected by HIV.

The policy was announced by the prime minister, Wen
Jiabao, when visiting AIDS patients in Ditan hospital
in Beijing. Both the policy and the visit were an
overdue acknowledgment that AIDS demanded a decent
government response, and that those who suffered from
it should not be treated as pariahs. The government is
trying to gather more information about the epidemic.
It is spending more: the budget for 2004 of 810m yuan
($98m) was over twice the budget for 2003. It is doing
more to promote education and awareness. And it has
brought in a requirement that all local officials
should be regularly assessed on their efforts to
combat AIDS.

Perhaps more bravely, it has also started to tackle
the problem of drug addiction by means other than its
traditional response of retribution and re-education.
Needle-exchange programmes have been introduced in
about 50 places in the south and north-west, and
efforts are at last being made at some centres—perhaps
100 by the end of this year—to use methadone to wean
addicts off drugs. The trouble is that in order to
prevent methadone treatment being seen as a soft
option, it is available only to people who have been
jailed three times for drug offences. Anyone meeting
that criterion will have been taking drugs for at
least five or six years, and will therefore probably
be thoroughly hooked and have shared hundreds of
needles.

A bigger difficulty is the scale of the measures being
taken, and the zeal or inertia with which they are
implemented. Foreign AIDS experts speak approvingly of
many of the Chinese officials who are engaged in the
struggle against the disease. But, in a country with
80,000 people suffering from full-blown AIDS, they are
pitifully few. Only three hospitals in Beijing take
AIDS patients, for instance, and Ditan, the main one,
has treated no more than 400 or so as in-patients and
another 700 as out-patients since its first case in
1987. China as a whole has only 50 AIDS doctors, and
only about 15,000 people are being treated with
anti-retroviral drugs.

Beyond Beijing, the energy with which the government's
policies are executed varies. China is vast and
decentralised, and clear orders from the centre may
reach the provinces as confused murmurs. If all
China's mass organisations, including the party, the
women's federation and the youth league, were truly
mobilised, then the “people's war” necessary to fight
the epidemic could be successfully waged. But the
leadership seems reluctant. And, despite its clear
concern about AIDS, old habits of repression and
secrecy often reassert themselves when, for instance,
gay websites offer information about AIDS.

Even so, some independent groups are trying to fill
the gaps. The Mangrove Support Group is one, which
promotes knowledge and offers care in five provinces,
as well as via the internet. Over 30 groups offer
assistance to homosexuals, and a few others like the
Positive Art Workshop in Beijing offer help and
therapy. In general, though, such groups are rare, as
are any non-governmental organisations—a problem for
the Global Fund, the partnership conceived at the G8
summit in 2000 to fight AIDS, TB and malaria: a share
of its cash is meant to be spent through NGOs.

If China is to contain its AIDS epidemic, it will need
help, lots of it, from international agencies and from
NGOs. AIDS everywhere presents a range of problems
that are not susceptible to solution by a single
agency. One big task, for example, is that of giving
information. Many Chinese are still deeply ignorant
about AIDS. The stigma attached to the disease is
potent, despite widespread sympathy for the peasants
of Henan, and despite the efforts of a few brave
people like Pu Cunxin, one of China's best known
actors, who campaigns tirelessly against prejudice.

A very different problem concerns treatment. China
produces only five anti-retroviral drugs with which to
concoct treatments for HIV-positive people. The
Clinton Foundation is helping, but more drugs are
needed for those who find these “first-line” ones do
not work, or work only with intolerable side effects.
No special drugs for children are available at all.

Another particularly acute problem concerns gay men,
most of whom in China are married. Although
homosexuality is no longer regarded as a psychiatric
disorder, convention and economic security in old age
combine to make marriage a desirable choice for nearly
all men. Few are therefore openly gay, though they may
well gather in certain bars, clubs or parks to arrange
sexual assignations. If they become infected—some say
1-5% of China's 10m-20m homosexuals are
HIV-positive—they will probably also infect their
wives.

The troubles do not stop there. How do you promote the
use of condoms in a society that prefers other means
of birth control, such as the coil, injections,
vasectomies or, as a fallback, abortion? How do you
ensure that condoms are sound in a country where
quality control is everywhere elusive? How do you
recruit health-workers to look after patients who are
widely considered dangerous and undesirable? How do
you get people to take HIV tests when they fear that a
positive result will mean they lose their job, as
infection with hepatitis often does already? How do
you mend a broken public-health system?

But first of all China must find answers to the
question of how to prevent a drugs-driven epidemic
becoming a sex-driven one. If it does that, it has a
good chance of containing AIDS. If not, it will
discover that all its problems multiply, as Africa
and, to a lesser extent, India have already found.
China does not have much time.

http://www.economist.com/World/asia/displayStory.cfm?story_id=4223578
_________________
Forwarded to the FORUM with greetings by
Phi Huynhdo <huynhdophi@...>