Chin Med J 2008;121(13):1230-1236 1230
Review article
HIV/AIDS epidemiology and prevention in China
SHENG Lei and CAO Wu-kui
Keywords: acquired immunodeficiency syndrome; China; disease outbreaks; prevention and control; public policy
Objective To review HIV/AIDS epidemic history, current situation and prevention policy in China.
Data sources Information included in this article was identified by searching PUBMED (1997–2006) online resources
using the key terms “HIV/AIDS”, “epidemic”, “prevention”, and “China”.
Study selection Original milestone articles and critical reviews written by major pioneer investigators of the field were
selected.
Results The key issues related to the HIV/AIDS epidemic situation in China and Chinese government prevention policy
were summarized. HIV/AIDS epidemic groups and trends for HIV transmission were discussed.
Conclusion In January 2006, 650 000 people were estimated to be living with HIV in China. The overall HIV/AIDS
epidemic is at a low level (0.05%) and concentrated in several at risk populations. However, the data show that new
cases of HIV infection are growing every year and spreading from at risk populations to the general population. Premier
WEN Jia-bao announced the “Four frees and one care” policy and the Chinese government has developed a series of
programs with strong policy measures to stop the spread of HIV/AIDS in China.
Chin Med J 2008;121(13):1230-1236
hina is a huge country with multicultural and
multiethnic characteristics accompanied by wide
geographic and socio-demographic variations. China’s
large and ethnically diverse population, its geographic
expanse, rapid economic growth, institutional transition
from a planned to an open economy, and the evolution of
social norms, have all shaped the growing HIV/AIDS
epidemic. In 2006 there were 650 000 people living with
HIV in China as estimated by the WHO, UNAIDS, and
the Chinese government. The overall HIV/AIDS
epidemic is at a low level (0.05%) and concentrated in
several at risk populations, although new cases of HIV
infection are growing every year.1
HIV EPIDEMIC HISTORY IN CHINA
Since the USA reported the first case in 1981, HIV has
become a worldwide epidemic. AIDS was first reported
in Beijing, China, in 1985. Since then the HIV epidemic
has become more visible in China. The cases reported are
increasing every year and have spread throughout the
country.1
Four phases of the HIV epidemic in China
First phase (1985–1988) was marked by a small number
of AIDS cases in coastal cities. The cases were mainly
foreigners or Chinese traveling overseas. Four
hemophiliac patients infected with HIV through imported
factor VIII were reported in Zhejiang Province.2
Second phase (1989–1993) began in October 1989 with
the identification of HIV infection in 146 drug users in
southwestern Yunnan Province. This was the first sign of
a local prevalence and isolated outbreak. The total
number of infected people at the end of 1989 was
reported as 153 Chinese and 41 foreigners.2
Third phase (1994–2000): In late 1994, HIV transmission
spread beyond Yunnan. A considerable number of cases
of HIV infection were reported among drug users and
commercial plasma donors from various regions. From
the mid-1990s, HIV has spread all over China and all
modes of transmission were reported. The national
figures for HIV infection quickly grew. By August 1996,
official statistics had reported 4500 cases of HIV
infection and 130 cases of AIDS. By 1998, HIV infection
had been reported in all 31 provinces, regions, and
municipalities.3
Fourth phase (2001–): The year 2001 was the start of the
fourth phase of the AIDS epidemic in China. It is the
stage when a number of key events took place which
suggested that the silence surrounding HIV in China was
beginning to end. These events include: (1) In June 2001,
the “China Plan of Action to Contain, Prevent and
Control HIV/AIDS” was published. The plan stated that
blood for clinical use would have to undergo complete
HIV testing and should be provided by non-profit blood
centers. (2) In August 2001, the Chinese government
published estimates suggesting that there were 600 000 to
800 000 people living with HIV/AIDS. Most of these
infections were caused by contaminated blood. (3) In
2003, AIDS cases cumulatively reported in China were
45 092 with 1800 deaths. The national estimate of the
number of people living with HIV/AIDS at the end of
C
Tianjin Infectious Disease Hospital, Tianjin 300192, China (Sheng
L and Cao WK)
Correspondence to: Dr. SHENG Lei, Tianjin Infectious Disease
Hospital, Tianjin 300192, China (Tel: 86-22-27468235. Email:
tjshenglei@yahoo.com.cn)
Chinese Medical Journal 2008; 121(13):1230-1236 1231
2003 was 840 000 (650 000–1 020 000), with a prevalence
rate in the general population of 0.07% (0.05%–0.08%).
The figure made China the 2nd highest country in Asia
and 14th in the world.4 (4) The 2003 Joint Assessment
Report concluded that in 1985, when the first HIV cases
were diagnosed, national HIV prevalence remained low
but clusters of high prevalence existed, both
geographically and among specific sub-groups. There
were indications that the disease was spreading from high
incidence groups to the general population.5 (5)
“Diagnostic Criteria and Principles of Management of
HIV/AIDS” was amended by the Chinese government in
2003. (6) In January 2006, the Chinese government along
with WHO and UNAIDS estimated that 650 000 people
were living with HIV in China (range 540 000–760 000),
including about 75 000 AIDS patients.6 The infections
remain concentrated among injecting drug users (IDUs),
sex workers and their clients, and homosexual men. The
new estimates are based on a much wider range of
surveillance data, as well as mass screening of former
plasma donors (FPDs), made at the prefecture level.
Limited data from high prevalence provincial surveillance
sites led to past estimates that now seem too high. The
figure of 650 000 is lower than previously published in
2003. It does not mean that HIV is now under control in
China but that estimates have been lowered due to
improved methods of estimation and better data. The data
from the national sentinel surveillance system shows that
the HIV epidemic in China is still growing. During 2005,
there were around 70 000 new HIV infections (range 60
000–80 000). Between 20 000 and 30 000 people were
estimated to have died of HIV in 2005. New infections
continue to outstrip deaths.6 (7) “Regulations on AIDS
Prevention and Treatment” adopted at the 122nd
Executive Meeting of the State Council on January 18,
2006 were hereby promulgated and should be effective as
of March 1, 2006.
HIV EPIDEMIC GROUPS
HIV in China is concentrated among populations
engaging in high risk behavior, such as injecting drug
users, former plasma donors, sex workers and their clients,
and men who have sex with men (MSM).7
Injecting drug users (IDUs)
Injecting drug use has been the dominant route for HIV
infection in China.8 Currently, there are one million drug
users in China. Sixty-one percent are injecting and over
50% share needles. They are mainly concentrated in
Yunnan, Xinjiang, Guangxi, Guangdong, Guizhou,
Sichuan and Hunan provinces. HIV/AIDS transmission
through injecting drug use is associated with 43.9% of
HIV infections in China.4 The average HIV prevalence
rates among IDUs increased from 0.04% in 1995 to 5.9%
in 2002, and even reached 20%–30% in some areas in
2001. Another risk of factor is the high turnover of sexual
partners among IDUs leading to further spread of HIV in
China. Behavioral surveillance shows that IDUs are also
more likely to buy and sell sex.7,8
Former plasma donors (FPDs)
A shortage of blood products in China led to a large
market for illegal commercial plasma/blood collections in
the 1980s and early 1990s. Hundreds of commercial
plasma collection centers were established in central and
eastern China. The paid donors were generally farmers
from poorer areas. Plasma donation was much more
popular than whole blood donation. Commercial plasma
donation with unhygienic re-fusion of red blood cells
(RBC) was common in rural communities in the early
1990s.8 Donation procedures reused unsterilized
equipment that allowed blood-borne infections to spread
rapidly through the local donor population. Since 1995,
the problem of HIV spread among FPDs has become
apparent. The outbreak of HIV/AIDS among FPDs was
mainly in Henan, Hebei, Hubei, Anhui, Shanxi and Jilin
provinces. The rate of FPDs infected with HIV was
between 10% (the lowest area) and 60% (the highest
area).9 By 2003, 24.1% of cumulatively reported
HIV/AIDS cases in China had been attributable to
commercial plasma/blood donation.4 The 2003 estimated
figure was 199 000 FPDs living with HIV. In 2005, the
estimated numbers of infected former plasma/blood
donors fell from 199 000 to 55 000.6 This group is now
reaching a stage of high mortality. It is estimated that
there were at least 10 000 deaths in 2005 alone.
Commercial sex workers
HIV infection among heterosexual groups are rising
rapidly because of flourishing commercial sex services,
despite China’s abolition of brothels in 1955. The
national estimate of the number of Commercial sex
workers (CSWs) in 2001 was about 4 million whose rate
of infection with HIV was above 10%. Large numbers of
CSWs in coastal area and big cities doing transient sex
work is now common in hotels, pubs, hairdressing salons,
bathing centers, massage parlors, song bars and ballrooms,
or from the streets. In 2003, heterosexual transmission
accounted for 8.1% of cumulative reported HIV/AIDS
cases in China.9 Along with the growth of commercial sex
and continued low rate of condom use, sexually
transmitted diseases (STDs) have increased sharply.10
CSWs have an important bridging role in transmitting
HIV from core groups to the general population.8
Men who have sex with men
There are up to 8 million MSM with a 1%–4% rate of
HIV infection in China. Unprotected sexual activities,
including group sex, anal sex, casual sex and commercial
sex are prevalent among Chinese MSM.11 While
homosexual activities are not illegal in China, they are
not considered socially acceptable. Homosexual or
bisexual men still hide their sexual orientation and often
marry women. Married MSM may acquire HIV from
their high risk male sexual partner and transmit it to their
wives.12 Cases of MSM infected with HIV account for
11.1% of accumulated cases that were reported in 2003 in
China.4 MSM has become a rapidly growing group in the
Chin Med J 2008;121(13):1230-1236 1232
HIV epidemic in China and they are at high risk of HIV
infection and contribute to the spread of HIV to women
and the general population.11,13 In addition, groups of
male commercial sex workers have appeared in large
cities. A survey show that 38% of MSM investigated in
four cities in China had paid for sex.2
POTENTIAL FOR HIV TRANSMISSION
HIV transmission in families
Studies in China have confirmed that HIV transmission is
occurring at the family level. IDUs, CSWs, FPDs and
married MSM may transmit HIV to their spouses and
children.14 Two recent studies among FPDs showed that
the rate of HIV sexual transmission among discordant
couples is 11% and the rate of mother to child
transmission (MTCT) is 38%.15 It is proven by a group of
orphans infected with HIV left by FPDs, that the spread
of HIV in China has reached the stage of MTCT. Since
the first case of MTCT was reported in 1995, the
proportion in MTCT has increased from 0.1% of the total
reported HIV-positive cases in 1997 to 0.4% in 2002.
Although pregnant women and children have been at low
risk of MTCT of HIV, an upward trend has been reported
since 2005.
HIV transmission through migration
China’s first case of HIV was a foreign traveler. With the
country’s open policy, China now has several million
international travelers visiting each year, and also large
numbers of Chinese travelers going abroad. There is also
a huge internal migrant population in China. There are
currently about 120 million migrant workers in China, of
whom about half are registered, nonpermanent residents
working in the fastest developing regions. Migrants are
largely young and sexually active. Both male and female
migrants are likely to be linked with commercial sex
when away from home. Data show that migrants also
have a higher proportion of IDUs and FPDs. Floating
populations are the most difficult to reach with preventive
health education and they tend to be deprived of access to
health care. China’s internal migrant labor population
may become the most vulnerable to HIV infection.16
Migrants may spread HIV/AIDS between rural and urban
areas as well as from HIV concentrated regions to low
prevalence regions. Migration of people is an important
factor that may accelerate the HIV epidemic and has been
the major factor in turning HIV/AIDS into a worldwide
epidemic.
HIV transmission in hospitals
HIV may be transmitted through medical equipment and
instruments, or via blood products in hospital. Unsafe
injections still occur in local clinics especially in rural
areas. On the other hand, doctors, nurses and technicians
working at laboratories may be infected with HIV after
exposure to HIV-positive blood during their work.17
HIV transmission in universities
A cross-sectional survey of 1326 students between the
ages of 17 to 28 was conducted in 2002. Results indicated
that 14% of Chinese university students are sexually
active and risk behaviours tend to increase with age.
Additionally, 24% of the students considered themselves
to be at a moderate to very high risk of contracting HIV
and 40% of sexually active students never used
condoms.18 In addition, the university students come from
different areas in China, or other countries, which may
lead to the spread of the HIV epidemic.
HIV PREVENTION IN CHINA
Two decades have passed since the first HIV/AIDS case
was described in 1981. Cumulatively, over 20 million
people have unfortunately lost their lives, more than 40
million people are now living with HIV, and most of them
are from developing countries. China, as the biggest
developing country, has an impact on the epidemic of
HIV/AIDS. From the first case of AIDS diagnosed in
Mainland China in 1985, the epidemic has spread at an
alarming rate.19 China, a vast country of 1.3 billion
people, faces tremendous logistical challenges in
combating the HIV/AIDS epidemic. Despite a downward
revision in 2005 (650 000) estimates from 2003 (840 000)
HIV/AIDS estimates, China still faces a growing
epidemic. WHO warned that, if there were no effective
preventive measures adopted, that the number of
HIV/AIDS cases would reach 10 million in China by
2010.19
The early cases of HIV/AIDS in China were mostly
foreign nationals. The Chinese government’s response to
early cases of HIV/AIDS was to stop and prevent HIV
from entering China. However, the policy was not
effective.20 Initially, the Chinese government’s AIDS
policy amounted to restricting entry into China of people
infected with HIV, as well as initiating measures that
reinforced the illegality of homosexuality and drug use.
As the epidemic continues to spread throughout China the
government has taken a much more active role in HIV
prevention, including creating policies to care for the
carriers of HIV. At the center of China’s HIV/AIDS
policy is the China CARES program (China
Comprehensive AIDS Response). China CARES
originally concentrated on AIDS patients who were
infected with HIV due to unsafe blood collection,
particularly in Henan Province. Recently, the China
CARES program has been expanded to respond to a more
diverse patient group and has increased its focus on
health education and comprehensive treatment. Although
the government was slow to respond to the epidemic in
the late 20th century, it has made a vigorous response
since the early 21st century. Components of that response
include implementation and evaluation of harm reduction
programs for IDUs, education to increase knowledge and
reduce stigma, treatment and social support for rural and
poor HIV/AIDS patients, widespread testing, and
increased funding for HIV/AIDS programs.21
Chinese Medical Journal 2008; 121(13):1230-1236 1233
To monitor the effectiveness of recent policy changes, the
government is conducting a mid-term evaluation of
China’s Medium and Long Term Program for the
Prevention of AIDS (1998). This program aims to limit
HIV infections to 1.5 million by 2010. The program’s
focus includes: ensuring safe blood collection and blood
use practices, implementing health education, and
providing care for HIV/AIDS patients and their
families.22 The mid-term evaluation will enable the
government to assess which prevention and treatment
strategies are effective and identify those that need to be
altered.
Blood donation policy
Unsafe blood collection is the cause of many AIDS cases
in China. The Chinese government has cracked down on
blood collection centers in an attempt to completely
eradicate HIV infections due to unsafe blood collection.
In 1995, the problem of HIV spreading among FPDs first
appeared. The Chinese government took strong legal
action to prevent further spread of HIV infection by
closing commercial plasma collection centers and issuing
new regulations for blood/plasma donations. In 1998, the
“Law on Blood Donation” became effective nationwide.
It requires HIV screening for all blood donations and
more than 85% of blood to be provided by non-profit
blood centers for clinical use.22 There have been major
achievements in ensuring that blood is collected safely.
Currently, volunteers donate 88% of the total blood
collection, up from 22% in 1998.
In 2002, the Chinese government updated its “Action
Plan” to reduce HIV infections to 1.5 million by 2010.
The new version included measures for blood used for
clinical purposes to be run though HIV screening, as well
as demanding that 85% of blood be donated by non-profit
blood centers, with the rest coming from authorized
hospitals for their own use.22
Starting from May 2004, the government has sponsored a
major nationwide campaign against unsafe blood
collection, in an attempt to shut down all illegal blood
collection stations. In May, two stations were shut down,
demonstrating the need for this kind of campaign. The
government has also passed laws to ensure that blood is
donated, not sold, and 26 provinces, municipalities and
regions have passed local regulations in accordance with
the laws.
Funding for blood safety has increased greatly in the past
five years. In response to the high number HIV infections
through contaminated blood supplies and illegal blood
donation, billions of RMB have been dedicated to
improving blood centers nationwide. Blood center
workers are also receiving more advanced training. In
2004, the Shanghai Blood Administration Office
implemented an identity card checking system to increase
the safety of the blood supply. This crackdown, along
with many others nationwide, demonstrated the
commitment of the Chinese government to stopping the
spread of HIV.
Methadone maintenance treatment and needle
exchange programs
Methadone maintenance clinics and needle exchange
programs (NEP) are now being implemented in China as
a response to the rapid increase in prevalence of
HIV/AIDS over the past 10–15 years. It is worth noting
that in prior years methadone was available only for
short-term detoxification from opiates and for research
purposes. To reduce the risk of HIV infection among