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Sex, drugs, and HIV/AIDS in China
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The Lancet, Jan 2008
Jonathan Watts
China has made impressive strides in the past couple of years to control the spread of HIV/AIDS but if it is to quell the new wave of infections in the general population, it will have to confront the country's changing patterns of sexual behaviour. Jonathan Watts reports from Beijing.
In most of the tens of thousands of gaudy neon-lit karaoke parlours that have sprung up around China over the past decade, customers are usually offered three menus. The first for songs, the second for drinks, and the third-always unwritten, and only explained to men-for sexual services.
It is a similar story in the countless pink-lit barber shops and massage businesses that can be seen in every town and city. In many hotels too, single male guests can expect to be propositioned in the lobby or by a call from the receptionist touting a special "room service".
The rise of industrial-scale prostitution has been one of the most visible signs of China's move from a closed, ideologically focused state to an open, market-driven economy. Coming alongside an increase in personal freedoms, rising affluence, the spread of the internet, and growing curiosity about overseas norms of behaviour, it has contributed to a far more permissive and promiscuous society than was the case in the past. The trend is apparent not just in brothels, but also in high schools and universities.
Until a few years ago, that might have been primarily of interest only to moralists and sociologists, but new statistics showing that heterosexual sex has overtaken intravenous drug use as the main route of transmission for HIV/AIDS has suddenly made sexual behaviour a central concern for public-health policymakers.
There was good news and bad news when the ministry of health, UNAIDS, and WHO released their latest annual estimate for the disease last November. Encouragingly, they believe the rate of increase slowed to 50_000 new infections in 2007, down from 70_000 new infections in 2005. Overall, they estimate China will have 700_000 people living with HIV by the end of 2007, including 85_000 AIDS patients. In a giant population of 1·3 billion, these statistics suggest prevalence is relatively low at less than one in 1000-far better than the worst predictions of UNAIDS and others at the start of the decade. This improvement is in part attributed to the measures taken by the government in 2003-04 to be more open about the problem, to improve public awareness, and to offer free testing and drugs.
The first bit of bad news is that the estimates are contentious. By the end of October, 2006, there were only 223_501 registered cases of HIV. The government extrapolates from this number to try to include those who are unaware they have the disease and those who cover it up because of the stigma attached to HIV. According to several non-governmental organisations (NGOs), local officials in some areas continue to massively underestimate the problem, especially with regard to infections caused by blood-selling operations.
A more disturbing trend, according to the health minister Chen Zhu, is that sex is now the main route of transmission. Of the new infections this year, 44·7% were passed on through heterosexual sex, 42% from intravenous drug use, 12·2% from men having sex with men, and 1·1 % from mother-to-infant transmission.
These figures confirm trends noticed earlier in several regions. According to the Shanghai media, 70% of HIV positive men and 80% of HIV positive women in the commercial capital were infected by their marriage partners. A contributing factor, according to UN officials and HIV activists, is that a relatively high proportion of homosexual men in China are married and bisexual.
Hao Yang, deputy chief of the disease prevention and control bureau under the ministry of health, told the China Daily that men who have sex with men are proportionately most likely to become infected by the disease. He said most had more than one sexual partner, less than one in five used condoms, and many were married so they spread HIV to their wives or children.
The Shanghai Public Health Clinical Center said 70% of the 77 new HIV patients it has seen this year were young and well educated. The head of the centre, Sun Hongqing blamed a lack of knowledge about sexually transmitted diseases.
Yunnan Province, which is close to southeast Asia's notorious Golden Triangle of drugs and prostitution, is thought to have been the entry point for the disease in the late 1980s. Studies there on different strains of HIV by researchers from the Rockefeller University and the Aaron Diamond AIDS Research Center suggest that the virus may be spreading through sex more quickly than previously believed. Yunnan's provincial government has been among the most proactive in countering the disease through public education, cooperation with foreign NGOs, and the provision of free condoms in all hotel rooms.
In April, 2007, Beijing city government declared a "new phase" in the spread of HIV/AIDS, and pointed to sex as a rising cause of transmission among the 12_000 people in the capital with the disease. Another important factor was the huge migration of rural workers into the city. The municipality said four of every five cases occurred among migrants. Anticipating further increase, the government said it will set up a monitoring network, as well as AIDS prevention clinics in each of the city's 18 districts before the end of 2008.
In Sichuan, the provincial Center for Disease Control and Prevention told the local media in November last year that HIV was spreading from high-risk groups to the general population. In the past, it said the sharpest rises in cases were among drug users and sex workers, but recently it was finding more infections through physical examinations of pregnant women, government officials, and young army recruits. Officials blamed the increase in early and casual sex, noting that young and promiscuous people are the least likely to use condoms.
It was a similar story in the central province of Hunan, which announced plans this summer for compulsory HIV tests for all workers in recreation venues, such as karaoke parlours. According to the local media, drug users account for most HIV cases, but the sharpest increase has been through sexual activity. Officials said the percentage of HIV infections caused by unprotected sex was less than 15% before 2006, but it rose to 38·7% in the first 6 months of 2007.
Few figures are available for China's burgeoning sex industry. But according to a study of two cities released last year by the National Centre for AIDS, between 3·4% and 3·6% of all adult females were sex workers. If this is the case nationwide, it would mean China has several million prostitutes.
The rapid changes in society have been evident in several recent surveys. The gap between the onset of sexual activity and marriage is growing. Last year, a study of high school students revealed that most found nothing wrong with a one-night stand. An earlier survey by the Family Planning Agency found that almost 70% of Chinese were not virgins when they married, compared with 16% at the end of the 1980s.
But sex education is far behind the trends. The government says it will step up its education campaigns, especially among high risk groups. It committed 944 million yuan (US$126 million) to HIV/AIDS work last year, up about 10% from 2006. As a sign of progress, the health ministry says condom use by prostitutes has almost tripled from 14·7% in 2001 to 41·4% last year.
Wan Yanhai, of the Beijing-based Aizhi advocacy group on AIDS issues, said the government has done a lot to educate people but he wondered sometimes whether it was sending out the right message. A couple of weeks ago, he said, the authorities introduced a new policy requiring all people who stay abroad for more than 1 year to have an HIV test, which he fears will lead people to wrongly assume that HIV/AIDS is a foreign disease.
The role of NGOs to identify such problems and offer solutions is crucial, according to the UN. But Chinese authorities continue to crack down on many groups that dare to criticise its handling of the epidemic. Political sensitivities were most apparent ahead of World AIDS Day, 2007, when a dozen HIV/AIDS patients in Henan were placed under house arrest during a visit by Prime Minister Wen Jiabao. The premier's trip to the area-one of the worst affected by the blood-selling scandal-was seen as a well intentioned attempt to raise awareness about the spread of the virus, but AIDS activists said the visit was stage managed by local officials so that he would never get to hear any complaints. Residents said about 1600 police had entered the village to ensure there were no embarrassing scenes.
China has made impressive strides in recent years to control the spread of HIV/AIDS, but if it is cope with the new wave of infections in the general population, it will have to confront unpalatable truths, whether in blood-selling villages or gaudy karaoke parlours.
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