HIV/AIDS trends in China

In the late 20th century, life expectancies in China increased and population growth slowed, leading to historical changes in the country's demographic profile. The national commitment to primary care and public health was operationalised through a rural cooperative medical system based on legions of so-called barefoot doctors and huge public health campaigns.¹ The revolutionary slogan “away with all pests” symbolised the popular attitudes towards malaria, schistosomiasis, trachoma, sexually transmitted infections, tuberculosis, and a host of infectious diseases that affected the nation.² Although China's global economic competitiveness benefited immeasurably from these advances in primary care and public health in the late 20th century, economic reforms after 1978, had the unintended consequence of reducing primary care access, especially in vast rural China when the cooperatives were dissolved.3, 4

Historians are sure to cite the value of a healthy workforce in contributing to the disproportionate global economic and political influence of China in the 21st century, similar to the situation in the UK and France in the 19th century, and the USA and former Soviet Union in the 20th century. However, the world's largest population—about one in five people in the word live in China—now faces the need to rebuild its health system.5, 6 China risks diluting its primary care and preventive focus in the face of medical commercialisation. China is coping with new health challenges related to modernisation and an aging population as a result of longer life expectancies and the nation's one child policy. Rising health-care costs in an aging population with commensurate non-communicable diseases are sure to serve as an economic drain on the Chinese economy, as in high-income countries and other rapidly developing nations like Brazil, Russia, India, and South Africa (ie, BRICS countries like China).⁷

Even as the number of cases of non-communicable diseases rise in China, the severe acute respiratory syndrome (SARS) coronavirus pandemic of 2002–03⁸ galvanised the Chinese Government to reform and revitalise its public health surveillance infrastructure for communicable diseases. A wide appreciation now exists that emerging infectious diseases from China could have a global effect, as with influenza reassortants that could humanise virulent avian or porcine strains. For example, influenza viruses could emerge more easily in China in view of human and animal population densities and traditions of food consumption and open marketplaces.⁹ Worldwide travel and commerce with the world's largest manufacturing and exporting nation are of a magnitude to spread any human infectious disease far from an emerging epicentre. Whether diseases are infectious or non-communicable, any upward trends in disease in China are of disproportionate humanitarian concern in view of China's estimated 1·35 billion population.

In this issue of Lancet Infectious Diseases, Lei Zhang and colleagues¹⁰ tackle the evolution of an epidemic challenge contemporaneous with SARS and influenza concerns—namely, HIV/AIDS. The investigators use the extraordinary public health data system—both hospital and clinic-based and sentinel surveillance—of the Chinese Center for Disease Control and Prevention (China CDC) to characterise trends and prevalence for HIV from all 31 provinces. As with most Chinese national reports, the two special administrative regions of Hong Kong and Macao, and Taiwan, are excluded. Although the systematic review of the published scientific literature is a valuable contribution, it is even more impressive that the authors (including leading China CDC epidemiologists) analysed prevalence trends between 1995 and 2010. 578 987 drug users, including 313 105 injecting drug users, were sampled from 295 national sentinel sites, along with 769 834 female sex workers (FSW) from 514 sites, and 87 255 men who have sex with men from 103 sites.¹⁰ Zhang and colleagues report that there is no one Asian pattern for HIV transmission. As elsewhere, geography, economics, and culture predict whether heterosexual, male homosexual, needle or syringe sharing to inject drugs, or contaminated blood, or blood products might be driving epidemic spread at any given time.¹¹

Although the investigators report a stable HIV/AIDS annual incidence in China in recent years, the patterns of transmission have evolved over time. In China, HIV infection in injecting drug users has fallen, remained stable at low levels in FSWs (although higher in southwest China),¹² and markedly increased in men who have sex with men. Cases among illegal blood donors have been eliminated, for all practical purposes, with the law enforcement crackdown on unscrupulous blood harvesters in the mid and late 1990s.¹³ This demographic shift is similar to other nations in the region, such as Thailand, and other large nations such as the USA, which have also had substantial changes in the subsets of vulnerable people who are disproportionately represented in recently incident cases. As in the USA since the grassroots distribution of clean needles and syringes (supported by the federal government for the first time in the Obama administration), China has seen the expansion of its needle and syringe exchange programmes and its methadone programmes associate with a marked fall in new HIV infections in injecting drug users.14, 15

At the end of 2011, estimates suggested that 780 000 (between 620 000 and 940 000) people were living with HIV/AIDS in China.¹⁶ 48 000 new infections were estimated for 2011, 52·2% infected through heterosexual transmission, 29·4% through homosexual transmission, 18·0% through injecting drug use, and 0·4% through mother-to-child transmission (the others unknown).¹⁶ Zhang and colleagues report that national trends, consistent across many provinces, suggest that men who have sex with men are a main subgroup of urgent priority for Chinese prevention focus.¹⁰ In partnership with non-governmental, community-based, and other advocacy organisations, the China CDC is in the process of expanding risk reduction education and testing services, and expanding antiretroviral therapy opportunities for infected individuals, both to help them and to reduce transmission to partners.¹⁷

China faces many challenges. In an effort to organise communicable disease health care outside of crowded urban centres, HIV care is located in hospitals inconveniently located outside of cities. In an effort to ensure control of antiretroviral drugs given without cost in the Four Free and One Care policy of the government, drugs are only available in selected venues. These structural obstacles inhibit coverage that could increase treatment as prevention successes. Methadone is available widely, but is not decentralised; buprenorphine is used rarely for opiate substitution treatment.¹⁸ Condom use is inconsistent and sex work has re-emerged as a major exploitive commercial enterprise. However, the openness of the China CDC with their data, their willingness to debate areas needing improvement, and their commitment to improving and expanding much needed prevention programmes suggest that more progress will be made to reduce HIV incidence.