The two main AIDS policy issues facing the Chinese government are preventing transmission of HIV/AIDS into the general population and the treatment of infected people. Other policy debates, which include targeting China’s marginalized sex workers and men who have sex with men (MSM) communities, needle exchange and condom distribution have prompted passionate debates between public and government officials and HIV/AIDS advocacy groups. This failure to agree on a consensus could limit any coordinated government effort to effectively control the transmission of AIDS.

HIV/AIDS Transmission to the General Population
The primary AIDS policy issue in China is the increasing risk of the AIDS virus spreading from localized high-risk groups into the general population through “bridge populations.” On 20 October 2003, the Director of the Chinese Centers for Disease Control and Prevention, Li Liming, admitted, "The biggest challenge we're facing is how to prevent the disease from transmitting to the general public from high-risk people such as prostitutes." China's “bridge populations” include the following groups:

“Floating population”
Unique to China because of the huge numbers involved, the term "floating population" (流动人口 liudong renkou) refers to the estimated 130 million migrant laborers who travel between China’s rural and urban areas. Some 65 percent of China’s migrant workers are male, with 20 percent in the 15 - 19 age group and 45 percent in the 20 - 29 age group. Chinese rural-urban labor migrants face many obstacles such as poverty, class differentiation, low skills and lack of access to education and health care. These factors isolate China's rural migrant workers in Chinese cities, placing them at the bottom of the social ladder. An increase in the HIV infection rate among China’s floating population group could spread the AIDS virus along migration routes into China’s major urban centers and throughout the countryside. Pan Xiaozhang, an AIDS expert at Shanghai's Hua Shan Hospital, warns that the influx of migrant workers in Shanghai is contributing to its higher HIV infection rate. He said many of Shanghai’s HIV cases are “migrant workers that stream in and out of Shanghai from rural hometowns throughout the country, an ideal conduit for further infection.”

In the area of health services, peasant migrants have no entitlement to the urban welfare system and have only limited access to healthcare in the countryside. Because of the high cost of health care, migrants only seek medical care as a last resort; leading to an increase of preventable diseases such as sexually transmitted diseases (STD). Preventative programs are virtually non-existent, and the abundance of STD clinic advertisements (both legal and illegal clinics) around migrant enclaves demonstrates the high prevalence of STDs among China's migrant population. The link between HIV and STDs and population mobility has been well established. Because migrants are isolated from their social networks, they are at increased risk to engage in high risk behavior that leads to the spread of HIV. Provinces with the largest emigration rates are Sichuan, Anhui, Henan and Hunan. An AIDS Weekly Plus article stated that 96 percent of global migrant workers are sexually active, but only 10 percent know how to prevent the transmission of HIV/AIDS.

Sex-workers and clients
China public security officials estimate there are up to three million prostitutes in China. Domestic migrants make up a large percentage of Chinese sex workers, who tend to be young and undereducated with little knowledge about sexual health. The national rate of HIV infection among prostitutes has risen from zero percent in 1995 to 1.32 percent in 2002. [Given that prostitution is illegal in China and there is no system of anonymous testing, only prostitutes in detention centers are routinely tested for the AIDS virus.] However, regional rates of infection tend to be much higher. In 2000, Yunnan province reported sex worker infection rates of 10.7 percent and Guangxi province 4.6 percent. In the first half of 2002, Shanghai experienced a 45.16 percent increase in HIV cases, with unprotected sex viewed as the main cause. Shanghai health officials showed that 80 percent of females and 20 percent of males were infected by their spouses, and some 67 percent of married and 45 percent of single males were infected by prostitutes or sex partners.

While local political leaders are quick to blame their unregistered migrant worker population for the rapid increases of HIV and STDs, a recent nationwide survey showed that the majority of clients of sex-workers are middle-class men under 35 years old.  The survey also showed that urban officials and businessmen are 10 times more likely, and rural officials and businessmen 22 times more likely, to frequent prostitutes than migrant laborers. This trend is likely to increase as China redirects its economic development priorities to its mid-level cities and towns.

Condom use among prostitutes remains low. A December 2002 survey of 800 sex workers in Yunnan and Sichuan showed only 60 percent used condoms with all their clients. About 17 percent said they insisted on using a condom when they had sex with their boyfriend or non-commercial sex partner. Of these women, fewer than 10 percent said they used condoms with their clients. The survey also polled 800 men between the ages of 25 and 45 who frequented prostitutes. About 40 percent said they had sex without using a condom.  

Experience has shown that the AIDS virus rapidly spreads from high-risk groups into the general population as the rate of sexual transmission increases. Chris Beyer of the John Hopkins Bloomberg School of Public Health concluded, “The African experience shows that once HIV is widely transmitted among reproductive-age adults, prevention becomes much more difficult.”

Male-to-male sex (MSM)
A recent study by the Center for AIDS Prevention Studies at the University of California - San Francisco (UCSF) published in the 21 June 2003 issue of The Lancet showed that men who have sex with men (MSM) could act as a "sexual bridge" for HIV transmission between high-risk men and low-risk women. Out of 481 Chinese male participants, fifteen tested positive for HIV, 238 admitted to having unprotected sex with a man in the past six months and 107 reported having unprotected anal or vaginal sex with a woman during the same period.  Also, the study showed the incidence of HIV infection was 4-5 times higher for men over 39 years old, than 39 and younger, "irrespective of the number of male sexual partners in their lifetime." Of the older men, 294, (64 percent) were married, compared to 53 (11 percent) of the younger respondents. The researchers note this pattern is similar to other Asian countries, especially India. While there were several attempts by low-ranking health officials to target MSMs in the early 1990s, today only under funded grassroots organizations are actively promoting AIDS awareness among China's MSM population.

Long-distance truck drivers
Another group which has the potential to bridge HIV from high-risk groups to the general population is long-distance truck drivers. Many smaller cities and towns have established truck stops, restaurants and small hotels, which provide truck drivers convenient access to commercial sex providers. In a recent survey, conducted among 550 commercial truck drivers in Yunnan province, nearly 17 percent had at least one STD. In this study, no driver was HIV positive. Long-distance truck drivers are a small, but highly mobile group which could potentially spread the AIDS virus through China’s rural regions and across its national borders.

Treatment of HIV/AIDS Infected Populations
Providing Free anti-Drugs
In April 2003, the Chinese government began a politically sensitive pilot program called China Comprehensive AIDS Response (China CARES).  This broad community-based treatment and care program aims to supply free domestically manufactured anti-retroviral (ARV) AIDS medication to HIV patients who contracted the AIDS virus through tainted blood transfusions. The initial phase of the plan calls for the estbalishment of 124 treatment centers and ARVs to be distributed to more than 3,000 people in 56 counties in 11 provinces, including the seven most affected:  Anhui, Henan, Hubei, Shanxi, Shaanxi, Sichuan provinces. By the end of 2003, the number of counties to be covered by China CARES is to increase to one hundred. As of July 2003, the program has distributed anti-AIDS medication to an estimated 61 people in Sichuan, 200 in Anhui and 420 in Hubei. In Henan's Shangcai county, 2,550 people are receiving medication, 200 in Xincai county and 120 in Queshan county.  The preliminary 56 counties were chosen based on the following reasons:
 

• History of unsafe blood collection practices with a high number of commercial blood donors.
• High levels of poverty.
• Highly mobile population.
• Local government at all levels willing to participate in and support the program.

Although the majority of China’s HIV cases are intravenous drug users, the decision was made to target HIV carriers who are former commercial blood donors. The Ministry of Health gave the following reasons why former commercial blood donors were chosen:
 

• After being infected up to 10 years ago, former commercial blood donors represent an underserved population and are beginning to develop AIDS.
• Former commercial blood donors are primarily concentrated in 56 out of China’s 2,800 counties, which will allow health officials to better implement its community-based treatment and care program.
• Once the China CARES pilot program is tested in these 56 counties, it can be expanded to target other high-risk groups, such as intravenous drug users and commercial sex workers and other areas.

In October 2003, China was granted a $98 million USD Global Fund to Fight AIDS, Tuberculosis and Malaria grant to expand China CARES. Combined with the $200 million USD provided by the Chinese government, the Ministry of Health intends to use this grant to increase the quality of care and significantly expand the number of HIV patients under treatment from 3,000 to 40,000 within these 56 counties. In five years, China CARES anticipates having 300,000 people who request voluntary testing and counseling, with more than 90 percent of HIV patients having access to care, monitoring and basic health services. These health services include treatment for opportunistic infections and access to supervised ARV treatment. According to the Ministry of Health, intravenous drug users and prostitutes in the targeted counties are also eligible for treatment and care.

Lack of Health Infrastructure
China lacks the healthcare capacity to effectively support the initial China CARES pilot program and its planned expansion. Currently, China possesses only 100 to 150 physicians are qualified to diagnose and treat HIV/AIDS and its resulting opportunistic infections. As a result, participants in the program have begun to drop out.  As of 14 July 2003, 327 of the 2,550 people in Henan's Shangcai county have dropped out because of the side effects caused by the anti-viral medication. Some side effects include vomiting and diarrhea, while others can be life threatening. "We have enough drugs, but we don't have enough doctors who can administer the drugs. Even in big cites in China, there are only a few hospitals with doctors who can administer the drugs," said China's Center for Disease Control's Zhang Fujie. Furthermore, there are limited numbers of case workers and laboratory technicians, who are needed to provide constant supervision and monitoring of program participants. The result of inadequate support can be devastating.

Providing free ARVs without proper patient supervision and counseling, and laboratory follow-up procedures to monitor viral loads, may have serious consequences. Viral load and CD4 tests must be performed on a regular basis to measure the effectiveness of the ARV regime and to evaluate whether any drug-resistant strains are developing. Unless a ARV "cocktail" regime is adhered to closely by the patient, the risk of a drug-resistant HIV strain developing increases significantly. As of August 2003, there was no additional viral load testing equipment to provide local level support, and no additional training programs have been established.

AIDS and Social Unrest
Beijing is aware that failing to provide substantial and comprehensive AIDS relief in these 51 target areas could lead to increased social instability.  HIV carriers from these areas have become more vocal and aggressive in demanding appropriate and substantial government provided health care. 

• In early 2002, a locally made video featuring more than 20 HIV positive villagers from Henan province was delivered to the United Nations, the Chinese Ministry of Health and the media. The video reportedly showed that the villagers, with official blood donation passbooks, donated blood at official government blood collecting stations.
• In March 2002, eight HIV positive villagers from Henan's Wenlou province protested at the Shangcai county's administration office demanding effective medicine and access to better health care.
• On 18 May 2003, up too 100 HIV positive villagers attempted to meet with visiting a World Health Organization (WHO) delegation.
• In June 2003, Shangcai county officials reported several villagers damaged government offices during another protest.

Faced with increasing social unrest, local authorities have increased their response to the increasing disturbances.

• On 18 May 2003, Shangcai county officials denied access to over 100 HIV positive villagers who wanted to visit the World Health Organization's (WHO) delegation in Henan.
• In June 2003, Shangcai county public security officials raided and arrested up to 16 people from Xiongqiao village in Shangcai county for their reported involvement in the June 2003 demonstrations.

Both Chinese and international AIDS organizations have called upon Beijing and Henan's local authorities to soften its treatment of the AIDS villagers.

Recognizing the conflict between China's official AIDS policy and implementation local authorities, the Ministry of Health will soon submit a draft of new regulations regarding the treatment of HIV/AIDS patients to the State Council for approval. These new rules will help clarify the "legal responsibility of local authorities to treat (AIDS) patients and prevent officials from covering up the spread of the disease," wrote the Financial Times. Mao Qunan, Deputy Director of the Chinese Health Ministry's Department of General Administration put forward the recent incident in Henan province, Xiongqiao village as an example of the difficulties of making sure that local authorities react appropriately to the AIDS situation in their areas. "We need to make clear the responsibility of each level of government for preventing and treating AIDS. We are stressing that it might be a better choice to handle things through law...just making spoken appeals [to local government officials] may not resolve the problems," Mao stated.

[China HIV/AIDS Chronology]
[China HIV/AIDS Blood Supply Chronology]

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