Report of an HIV/AIDS Assessment in China

 

 

July 30-August 10, 2001

and

August 28-30, 2001

 

 

 

National Center for HIV, STD and TB Prevention

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

 

 

 

Field Assessment Team (July 30-Aug 10, 2001)

William E. Brady

Tina Chung

Richard G. Jenkins

Eve Lackritz

Christopher Murrill

Richard Needle

Phillip Nieburg (team leader)

 

 

Collaboration Discussion Team (Aug 28-30, 2001)

Helen D. Gayle

Carmine J. Bozzi

Phillip Nieburg

Table of Contents

 

Executive Summary

 

Part I. Introduction and Background

A.     Information Sources

B.     Background Information

Current HIV-related economic, social and cultural issues in China

C.     Epidemiologic overview of HIV in China

 

Part II. Assessment Findings

A.     HIV/AIDS Surveillance Systems

1. Sentinel Surveillance
2. HIV/AIDS Case Reporting

B.     Public Awareness of HIV, including Voluntary Counseling and Testing

C.     Heterosexual transmission of HIV

1. Sexual Behavior
2. Heterosexual Transmission
3. Sexual Mixing and Bridge Populations

D.    China¡¯s Sexually Transmitted Infection (STI) Situation

1. STI Epidemiology
2. STI Surveillance
3. The ¡°Floating Population¡±

E.     HIV Transmission through Injection Drug Use

1. Epidemiology
2. Prevention Response

F.      Homosexual Transmission of HIV

G.    HIV Transmission via Transfusion and Collection of Blood Products

1. Blood Safety and HIV Infection in Blood Product Recipients
2. Blood Safety and HIV Infection in Blood Product Donors

H.    Transmission via Medical Injections

I.       unused section

J.      Mother-to-Child Transmission

K.    Tuberculosis

L.     HIV/AIDS Care

 

Summary Recommendations

 

Acknowledgments

 

 

Executive Summary

While the first HIV infection was reported in China in 1985, the country is still relatively early in its HIV/AIDS epidemic. There is some concern that officially reported HIV and AIDS cases underestimate the spread of HIV in China. However, even if officially reported statistics are accepted, it is clear China now faces a large, rapidly growing and exceedingly complex HIV problem that carries potential risks for the country¡¯s future development.

 

Although only about 28,000 HIV-infected persons have been officially reported in China through September 30, 2001, it is generally acknowledged on the basis of sentinel surveillance data that at least 600,000 Chinese may have already been infected by HIV. China¡¯s United Nations HIV Theme Group (UNTG, composed of representatives of all U.N. agencies working on HIV issues in China) estimates that current HIV infections exceed one million. The rate of increase in the number of infected persons has been about 30% per year over the last several years. The increase in reported HIV infections in the 12 months ending on June 30, 2001 was 67% greater than in the prior 12 months and the reported increase in the first nine months of 2001 exceeded the total of HIV infections reported in all of 2000. At the current rate of spread, the Ministry of Health (MOH) acknowledges that as many as 10 million people may become HIV-infected by 2010. On the basis of their larger estimate of the current disease burden, the UNTG predicts than 20 million HIV infections will have occurred by 2010. Enhancements to China¡¯s HIV surveillance programs and practices can help make these estimates more precise and can thereby lead to better planning.

 

At least three different HIV epidemics are now known to be occurring in China: (1) an epidemic among injection drug users (IDUs), concentrated until recently in western and southern China and related to the sharing of needles and syringes by IDUs; (2) a heterosexual epidemic, initially concentrated in provinces along the eastern coast of China and apparently at least partly related to HIV transmission to and from prostitutes and their clients; (3) an epidemic in provinces in east-central China related to exposure of paid plasma donors to HIV-contaminated blood during the donation process. In addition, HIV transmission from two other sources is of current concern: (4) transmission related to re-use of syringes and needles in the clinical practice of traditional and ¡°Western¡± medicine and (5) transmission related to transfusion of inadequately screened blood or blood products, related in part to insufficient numbers of unpaid blood donors.

 

Two other related disease issues are relevant to China’s current HIV situation. One of these is the spectrum of non-HIV sexually transmitted diseases or infections (STD or STI). Although STIs were apparently eliminated as a disease issue in China in the mid-20^th century, a resurgence has taken place over the last 20 years. The number of reported STIs, including the ulcerative STIs that are known to facilitate HIV transmission, has doubled over the four years from 1996 to 2000. The number of reported STIs is itself acknowledged to be a significant underestimate of the true STI burden, due to self-treatment practices and to low disease reporting from both the private medical and public health sector. STI surveillance in China is carried out by a component of the MOH outside the Academy of Preventive Medicine, where the National Center for AIDS Prevention and Control (NCAPC) resides and no formal linkages exist between STI and HIV surveillance or control programs.

 

A second current disease category related to HIV is tuberculosis (TB). China has a very large number of persons infected with TB, a disease that has proven to be a major (and in some places, the largest) co-infection problem among HIV-infected persons in all countries with established HIV epidemics. This TB co-infection problem is compounded by the clear demonstration in several studies that HIV and TB each accelerate the clinical progression of the other infection. Currently, few links exist between TB and HIV programs at any level within China. Persons under treatment for active TB are not routinely tested for HIV. Although some HIV-infected persons may have their TB status assessed, this step is not yet a routine component of clinical care for HIV infection. TB clinics or TB patients are not yet included among China’s current sentinel surveillance populations for HIV.

 

Two other HIV transmission issues that are likely to increase in importance as HIV continues to spread in China are mother-to-child HIV transmission and HIV transmission among male homosexuals (MSM, or men who have sex with men.). Current limited data suggest that HIV remains at low prevalence within these two groups but the prevalence is likely to begin rising as overall HIV prevalence in China rises. Available data about risks in these two groups are currently very limited.

 

Many persons in leadership roles in the Ministry of Health (MOH), the State Family Planning Commission (SFPC) and health bureaus at the provincial, prefectural, county and local levels are clearly aware of the seriousness of the problems that HIV/AIDS poses for China. However, our sense is that current prevention efforts in China are not yet sufficient to address the magnitude of China¡¯s HIV challenge. First, the single most critical issue is that awareness of accurate information about HIV transmission and HIV prevention remains limited among the general population, among vulnerable groups, and (apparently) among at least some health workers and other opinion leaders. This awareness gap needs to be addressed as a priority. Second, although many prevention activities have been discussed and, in some cases, begun, most efforts are of a ¡°pilot¡± nature in scale and scope. There is both a need and a current opportunity to begin increasing the size and population coverage of interventions that have been successfully pilot-tested in order to reach a larger proportion of the Chinese population. Third, the availability of trained staff and other resources allocated to HIV and STI control is not yet sufficient at most levels of government (national, provincial, local). Fourth, although staff in both the Ministry of Health and the State Family Planning Commission are actively discussing HIV control issues, the apparently limited participation to date of government ministries beyond those two entities suggests that decision-makers elsewhere in government have not yet been fully convinced of the magnitude of China¡¯s HIV risk.

 

In addition to these concerns, other social factors such as poverty and the illegal and stigmatized nature of some activities (e.g., intravenous drug use, sex outside of marriage, prostitution) associated with HIV and STI transmission appear to be major obstacles to publicly discussing and implementing effective interventions. For example, difficulties in providing broader population access to measures to reduce needle sharing among IDUs and to promote use of condoms in non-monogamous sexual relationships highlight the conflict between current laws and social practices on one hand and the goals of reducing HIV transmission on the other hand.

 

Finally, some of the many changes rapidly occurring within China (e.g., increasing economic growth, changing sexual behaviors and the large amount of migration in search of economic opportunity) are probably also helping facilitate the spread of HIV and other STIs.

 

The most worrisome aspect of those aware of China¡¯s current HIV situation remains the possibility that a heterosexual epidemic of HIV could occur and be sustained in China. In this regard, two important opportunities appears to exist at this moment: (1) through societal and other public health measures to prevent HIV transmission, to reduce the rate of spread of HIV within China and to thereby reduce and or delay the impact of HIV and associated conditions on the Chinese society and on vulnerable individuals and (2) to begin development of appropriate national and local care and treatment practices, guidelines and models that will surely be needed to address the growing number of HIV-infected persons who develop symptoms of AIDS in the future.

 

Despite these concerns and obstacles, progress in HIV control is being made in China. Discussion of HIV infection caused by non-sterile blood and plasma collection and of other HIV-related issues have appeared in Chinese media with increasing frequency in recent months, including several articles in English language newspapers during our brief time in Beijing. Recent press conferences and other public discussions of HIV by senior Chinese leadership indicate rapid changes in awareness of HIV risk. The Ministry of Health has demonstrated steadily increasing commitment to addressing HIV issues. China’s November 2001 National AIDS/STI Conference appears to indicate the beginning of a new level of attention to HIV/AIDS issues.

 

Despite this attention, agencies tasked with creating HIV control programs in China lack sufficient funds and technical resources to carry out these responsibilities. China’s HIV control activities could benefit from additional targeted external support focusing on the issues that have been and will be raised as priorities by the Ministry of Health, the State Family Planning Commission and other ministry level groups in China.

 

Assuming that a consensus can be reached on a program of collaboration, participation from CDC and other U.S. Government agencies could play major role in helping address the resource and technical needs faced by China.

 

Initial discussions and further exchanges of visits have taken place regarding potential collaborations between the U.S. CDC’s Global AIDS Program (CDC/GAP) and China’s NCAPC. Although many operational details and resource issues remain to be worked out, initial CDC/GAP activities are likely to focus on various aspects of HIV/AIDS surveillance (e.g., case surveillance, sentinel surveillance, behavioral surveillance, laboratory surveillance, rapid assessment among high risk groups, etc.) and to include training as well as system evaluation and design. These initial surveillance-related activities may also involve aspects of surveillance for other STIs and for tuberculosis. Subsequent work will focus on other issues jointly identified in the August 29, 2001 meeting between Minister Zhang and Dr. Gayle. (See summary recommendations)

[End of Executive Summary]
Part I. Introduction and Background

 

With the background of increasing global awareness of the severe impact of HIV infection on the people and economies of a number of sub-Saharan African and Caribbean countries, recent attention has begun to focus on the large and growing threat of HIV to Asian countries, where much larger populations are at potential risk from HIV and its consequences.

 

China is one such country. Recent estimates of HIV infections accepted by Chinese government officials have been in the range of 600,000 infected persons, with as many as 10 million HIV-infected persons acknowledged as a possibility by 2010. The UN HIV Theme Group has recently suggested that 20 million HIV infections are possible by 2010, based on an epidemic doubling time of 30 months.

 

Against this background, discussions and exchanges of visits over the last several years between staff of the Chinese Academy of Preventive Medicine (CAPM) within China’s Ministry of Health and the U.S. Centers for Disease Control and Prevention (CDC), a component of the U.S. Department of Health and Human Services, led to a decision for a team from CDC’s National Center for HIV, STI and TB Prevention to conduct the current HIV/AIDS assessment in China. Subsequent to that decision, Chinese Minister of Health Zhang addressed the UN General Assembly, discussing his concern about the spread of HIV in China and reiterating his government’s commitment to address the issue. At the same time, the Chinese State Council issued a new Five-year Action Plan setting out HIV/AIDS control goals for the period 2001-2005. In addition, as pointed out to us by both U.S. and Chinese government staff, Secretary of State Colin Powell and Chinese Foreign Minister Tang explicitly discussed the issue of HIV/AIDS with during Secretary Powell’s July 28-29 visit to Beijing, just days prior to the beginning of this assessment. Finally, letters on the issue of HIV prevention and care in China have been exchanged between Health Minister Zhang and U.S. Secretary of HHS Tommy Thompson.

The primary purpose of this assessment was to identify potential opportunities for CDC and other institutions of the U.S. Government to work with Chinese government organizations and other groups working in China on issues of HIV prevention and care. The assessment was conducted keeping several key concepts in mind:

 

1.      The single most important HIV issue for China may be whether HIV infection will, as has happened in some other countries, become a widespread endemic disease of the general population, sustained by heterosexual transmission. Although the team heard reassurances that this process was unlikely to occur in China, these reassurances appeared to be based more on wishful thinking than on information.

 

2.      In most societies, HIV/AIDS, other sexually transmitted infections (STI), tuberculosis (TB) and several other related infections are a constellation of related health conditions that have both individual and societal causes and consequences. As in other countries, a sustained multi-sectoral response to these issues will be required to mount an effective response in most circumstances.

 

 

A.     Key Information Sources for this Assessment

The assessment team reviewed and utilized printed and electronic material from multiple sources to conduct this assessment. However, the key sources of information for this assessment were:

 

¡¤        from China¡¯s General Office of State Council, China HIV/AIDS Containment, Prevention and Control Action Plan (2001-2005) (document translated for reference). Beijing, May 25, 2001. We reviewed the official English translation.

¡¤        Field notes and impressions gained during meetings with government, UN and other officials in Beijing and in the four provinces, including county and local level visits in those provinces. These meetings included a frank and detailed ninety minute discussion with Dr. Zhang Wenkang, China¡¯s Minister of Health. And his senior staff.

¡¤        Documents provided to us during visits to the four provinces of Guangxi, Guizhou, Hunan, and Yunnan.

¡¤        from the UN Theme Group on HIV/AIDS. AIDS in China: An updated assessment of the HIV/ AIDS situation in China, 20 June 2001. UN Theme Group, Beijing, released August 7, 2001. The UN Theme Group is comprised of all UN agencies with HIV-related activities in China. (available at URL <www.unchina.org/unaids/ekey1right.html>)

¡¤        From the World Bank, Plan of Project Implementation, (the Health IX Project Paper), January 24, 1999.

 

B.     Relevant Background Information on China

 

This section provides some brief context for the CDC HIV assessment. Additional information can be found in great detail in ¡°Background Note: China,¡± published in July 2001 by the U.S. Department of State (1).

China¡¯s total population (1999, UNFPA): 1,255,698,000 (1.3 billion estimated for 2001) Population aged 15-49 (UN Pop 1997): 704,949,000 Urban Population (UN Pop Div 1997): 32% (Rural = 68%) Infant Mortality Rate (UNICEF 1999): 38/1000 births Maternal Mortality Rate (UNICEF 1998) 900/100,000 pregnancies Compulsory education through 9th grade Adult Literacy, Male (UNESCO 1999): 90.8% Female (UNESCO 1999): 74.5% Life Expectancy, Male (UN 1998): 67.9 years Female (UN 1998): 72 years Per Capita Income (World Bank 1999): $US860 People: Han Chinese constitute the largest ethnic group, about 92% of total population. There are at least 11 other smaller ethnic groups. Language: Mandarin, the predominant dialect and official language, is spoken by more than 70% of the population. However, there are seven major Chinese dialects and many local sub-dialects.

 

C.     A brief summary of current HIV-related economic, social and cultural issues in China

 

1. Economic Issues:

The progressive change from a planned economy to an open market economy is now leading to rapid economic growth in certain areas of China. Incomes of some segments of the population are increasing rapidly. Many people now move from place to place for employment purposes, leading to a large ¡°floating population¡± (estimated to be as large as 100-120 million people living away from their official residences) who are thus deprived of access to some services. (A new law in effect since October 2001 is designed to allow some persons in the floating population to change their official place of residence, assuming that they meet certain employment criteria.) Increasing disposable income as well as increasing migration for work are both probably related to the increasing numbers of men said to frequent prostitutes. In addition, rural incomes have been rising less rapidly than urban incomes. The limited number of opportunities for women to earn money in rural areas has been linked to rising numbers of young women said to be providing sexual services, either after migrating to cities or large towns or to facilities along the rapidly expanding modern highway system.

 

At the same time, China¡¯s health care system is changing, the net effects of which is that health care costs to individuals are rising and perhaps that access to services will be further reduced as a fee-for-service-like system comes into existence. Because public health is not perceived to be an income-producing or cost-saving aspect of health care, it is likely to be undervalued in the current setting. Each of these changes is likely to have a greater impact on HIV/AIDS issues in rural than urban areas.

 

One final point is the observation that most HIV program funding has come and may continue to come from provincial and local health budgets. Although the national government is a source of guidance on HIV control and other health issues, a large amount of program autonomy remains at the provincial level and below.

 

2. Social Issues

China¡¯s private sector, although growing, remains small. In the United States and many other countries, NGO¡¯s are able to effectively harness resources to address issues that are sometimes politically difficult for national governments to address, such as outreach to stigmatized populations. Relatively few foreign non-governmental organizations (NGOs) operate in China and domestic NGOs are chartered by the government, somewhat (although not entirely) limiting their independence. However, the potential for public-private partnerships of the kind that have proven useful for HIV and STI control in the United States and other industrialized countries remains limited for the moment.

 

The related and partially overlapping issues of stigmatized and illegal behaviors are also of major concern. Many behaviors and activities associated with HIV transmission (e.g., prostitution) are illegal or stigmatized or, as with heterosexual sex, are themselves topics that are difficult to address in public discussion (e.g., intravenous drug use, heterosexual sex, homosexual sex, paid donation of blood products, needle and syringe re-use, etc.)

 

 

3. Legal and Regulatory Issues

As explained to the assessment team, China¡¯s legal system does not currently provide optimal support to the concept of HIV control. Legal and regulatory obstacles were described in three main categories:

 

(a)    Existing laws and regulations that impair HIV prevention or treatment effectiveness. One example described to us was a prohibition on display of condoms in public settings, which had the effect of limiting the ability of educators to teach people at risk of heterosexual transmission of HIV how to use condoms.

 

(b)   The absence of laws or regulations that could facilitate the effectiveness of HIV prevention or treatment programs. An example mentioned to us in several meetings was the absence of clear protection of the confidentiality of persons who might otherwise wish to be HIV-tested in a formal HIV counseling and testing program.

 

(c)    Absence of enforcement of existing laws and regulations. One example told to our team is the law or regulation requiring that the public media (TV/radio/newspapers) provide a certain amount of free time (or space, in the case of newspapers) for public service announcements, e.g., for HIV prevention messages. We were told that the media in question, despite awareness of the law or regulation, insisted on charging its usual ¡°commercial¡± rates for HIV prevention advertisements, thus severely limiting the amount of advertising that could be done.

The fact that China¡¯s new Five Year (2001-05) HIV Action Plan acknowledges many of these and other legal and regulatory issues suggests that at least some of them are likely to be addressed soon. The assessment was made aware of at least two processes of review of legal issues underway, one within the government and one supported by the Ford Foundation

 

 

D.     A Brief Epidemiological Overview of the Evolving HIV/AIDS Situation in China

 

China¡¯s early HIV epidemic has occurred in three main phases to date:

¡¤        1985-1989: The first HIV infection was reported in China in 1985. Sporadic HIV infections were reported mostly among Chinese returning to mainland China from extended stays overseas;

 

¡¤        1990-1994: A geographically limited HIV epidemic began among IDU in southern areas of Yunnan Province bordering Myanmar, with sporadic HIV infections elsewhere in China.

 

¡¤        1995-2001: among IDU, HIV infection spreads thr