China’s Impressive Performance on HIV/AIDS

Sex is a controversial yet evolving issue in China. In this field, like many others, the country’s economic boom and opening to the world are clashing with traditional values. China has become a destination for international immigration, which has resulted in more interactions between locals and foreigners, the latter often more liberal in their lifestyles. This contact is one of the factors that have fueled what has been labeled a slow sexual revolution.

This still nascent revolution has a great many obstacles to overcome. One of them is how rigorously the social sphere is protected in China against any sexual manifestations – pornography is a good example. Research conducted by experts from Harvard University in 2013 showed how, along with censorship itself, pornography is the only issue that is systematically censored in Chinese social media. This suppression is done on a scale even greater than that against posts critical of the state, political leaders, or public policies. The reason is that, according to Chinese officials, pornography violates public morality, damages the health of young people, and encourages disorder and chaos. It is noteworthy that this conservative attitude takes place in a country not driven by religious values, where most citizens profess no religion at all.

The tension resulting from holding a traditional mindset in modern times is reflected in public policies and engenders some thought-provoking controversies. For instance, local authorities in Beijing started in 2004 a campaign to set up more condom vending machines in the city. The anti-theft devices installed had to be removed when users complained about the noise they made when condoms were removed, which discouraged use.

These condom machines were installed in places like universities, where they were unwelcome – both Tsinghua and Peking universities got rid of theirs. Meanwhile, a group of promoters from a Beijing Health Bureau were not allowed to distribute free condoms on their campuses. But the battle is yet not over. The government in Beijing recently decided to mandate the re-installation of condom machines in all universities, as well as requiring sex education classes. The reason why the government is pursuing these health policies despite public opposition is simple: AIDS.

China has been fighting AIDS for 30 years. According to data by UNAIDS, the Joint United Nations Programme on HIV and AIDS, in 2004 there were 650,000 people living with the virus in the country. By 2009, AIDS had become the leading cause of death among infectious diseases, according to an official report by the Chinese government. “It is not a widespread epidemic but that infection rate has been rising rapidly,” stated Dr. Jian Hua, delegate of the United Nations General Assembly. A 2002 article noted that without more concerted government action, HIV and AIDS could potentially affect 10 million people by 2010. The document’s title was clear: “China’s Titanic Peril.” Not surprisingly, AIDS became a government priority.

The pattern of the newly infected people has shifted from traditional risk groups – sex workers and intravenous drug users – and now threatens the general population. Tackling this growth is particularly important when it comes to young people. Between 2008 and 2012 the number of cases doubled among students, with 95 percent sexually transmitted. The latest health policies aim to eliminate the threat by raising awareness and facilitating access to protection. In doing so, they favor a social movement.

AIDS Legislation in China: A Gradual Change

Initially, AIDS and HIV were characterized in China as being a consequence of contact with the West. This view resulted in ineffective regulation that was finally overcome through waves of legislation that have been progressively more successful. In this evolution, active collaboration among international organizations, NGOs, and private companies has been fundamental, making this issue an interesting one to study. The Chinese government, staunchly opposed to international interference in domestic issues, has been forced to collaborate with outside institutions to solve a domestic problem, and has done so with a degree of success.

AIDS first appeared in China in 1985. The first reported case was a foreigner, and for three years the only cases reported involved either foreigners or Chinese nationals who had been infected abroad. The first case originating from within China’s borders was discovered in Yunnan, where in 1989 a community of intravenous drug users had become infected. From there, the disease began to spread, driven by several social factors. The emerging market economy accelerated the spread of migrant workers across the country, favored by a reform of the hukou system in 1980 that made it less restrictive. The modernization of the Chinese economy also brought with it much greater individual freedoms, which meant a certain amount of sexual liberalization. Other scandals related with blood transmissions exploded around the same time.

AIDS was coming from abroad, so the strategy adopted by the Chinese government in this initial phase was focused on prevention. Imported blood products were banned and a Frontier Health Quarantine Law was established. All foreign students were forced to take an AIDS test before entering the country. Even today, students coming to China still have to take the test as part of their medical examination in order to obtain their visa. Thereafter, policymakers twice reformed the legal structure in a bid to combat the disease’s spread. After a first legal framework shift, authorities focused on stopping transmissions within the country. To do so, tougher legislation on prostitution and drug use was implemented with the goal of isolating the infected. As happened in many other countries and as studies had predicted, this approach proved ineffective.

Successful Cooperation

The final change in attitude came in the mid 1990s, when growing scientific evidence demonstrated that the spread of the virus could be reduced by applying certain techniques and programs. Chinese authorities began to pay careful attention to this body of research. An initial approach was made in 1997, when the Chinese Academy of Preventive Medicine and the University of California Los Angeles (UCLA) organized a workshop on AIDS and health policies from a multidisciplinary perspective. Chinese officials and representatives of international organizations such as the United Nations, the World Health Organization and the World Bank participated.

This multilateral cooperation represented a complete change in perspective for the Chinese government and produced a new approach to legislation. When Chinese officials expressed their willingness to accept overseas assistance, they received the support of the United Nations through its Drugs Control Programme. This institution has made a significant contribution to the development of essential policy planning documents, such as the Medium and Long-Term Strategic Plan for HIV/AIDS (1998–2010), the Action Plan on HIV/AIDS Prevention and Containment (2001–2005), and general Chinese AIDS regulations.

As a result of this cooperation, Chinese authorities adopted a new approach. Officials went on a tour to study the reaction of other countries that were making strides in stopping the spread of AIDS, including Australia, United States, Brazil, Thailand, and some African countries. Some of the lessons learned there were later applied, preceded by small pilot projects that showed efficacy. These changes finally became official in 2003, with the successful and highly advanced Four Free One Care policy: free antiretroviral drugs, free prevention of mother-to-child transmission, free voluntary testing and counseling, free schooling for children orphaned by AIDS, and care for people living with the virus.

An illustrative example of this kind of project is that which was applied to prostitution. Sex work is illegal in China and legislation had become increasingly strict, but it remained ineffective. The government decided to target this high risk demographic with a condom campaign inspired by Thailand’s initiative, which has proved to be a great success. The rate of condom use rose from 55 to 68 percent and, as a collateral outcome, the spread of some other diseases was also reduced. The prevalence of gonorrhea fell from 26 to 4 percent and chlamydia from 41 to 26 percent. Unequivocal evidence can be found in linguistics: The Chinese term for condom changed from biyuntao (避孕套), literally meaning “sheath to avoid pregnancy” to anquantao (安全套), “safety sheath.”

From Australia, the Chinese authorities adopted the needle exchange program. This initiative is partly funded by the World AIDS Foundation and has been expanded to many other countries. It complements other steps targeting drug users, like more frequent controls on smuggling and the opening of detoxification centers funded by the health system. Some other areas have also seen specific initiatives aimed at preventing mother-to-child transmission. This area has had financial and technical support from UNICEF and has produced satisfactory results – overall participation in testing was 92 percent in 2002.

This increasing openness on AIDS issues has been accompanied by several public statements in which the government has encouraged the participation of both private sector and NGOs, which have become fundamental actors in this struggle. Even Wang Longde, China’s vice minister of Health, publicly declared that “China encourages non-governmental organizations’ participation in the country’s fight against HIV and AIDS.” A good indicator of the success of this cooperation is the number of initiatives that are currently underway. There are dozens of different projects sponsored by the private sector targeting the problem around the country. China Rainbow Organization, based in Chongqing, plays an important role in preventing the spread of HIV among homosexuals with financial help from the British Barry & Martin Trust Fund. Merck, the U.S. pharmaceutical giant, is spending about 30 million dollars over a period of five years to train healthcare professionals, distribute condoms, and identify high-risk groups. Merck’s German counterpart Bayer has set up a training course in HIV and AIDS issues for journalists. About 300 reporters have completed the course so far at Tsinghua University. These are just some of the most prominent examples; there are many more.

A Paradigm for the Future

Current Chinese health policies on HIV and AIDS are an outcome of increased political commitment, growing scientific information, and external influences. This coordinated response has not only been necessary because of the global threat that AIDS poses, but also because of the architecture of China’s political system. Its hierarchically departmentalized structure is a design ill-suited to a successful AIDS response, which tends to be based on multifaceted and heavily interrelated activities. This process of joint action has culminated in the current legal framework, under the title of AIDS Prevention and Control Regulations. This law works together with the five-year action plan and the 2003 China CARES, a comprehensive response to assisting regional authorities providing care to patients under the Four Free and One Care program.

The history of AIDS legislation in China is a history of impressive progress in a time of social conscience modernization. The Chinese government has achieved a remarkable turnaround in its response, seeking more effectiveness, and has implemented a wide range of strategies to target high-risk groups and to improve the general population’s knowledge. Cooperation between the Chinese government, international organizations, private companies, and NGOs has been fundamental to this approach. China’s success is an encouraging precedent for other global issues that require worldwide action, such as environmental concerns, terrorism, and drug trafficking.