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China Meets New AIDS Challenges Zunyou Wu, MD, Phd* and Yu Wang, MD, Phd†

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China Meets New AIDS Challenges Zunyou Wu, MD, Phd* and Yu Wang, MD, Phd† INTRODUCTION China Meets New AIDS Challenges Zunyou Wu, MD, PhD* and Yu Wang, MD, PhD† ince acknowledging the HIV/AIDS epidemic,1,2 significant efforts to understand the Sepidemic in China have been undertaken resulting in a comprehensive policy response based on those understandings.3,4 From 2003 onwards, China has implemented ambitious treatment, prevention, and control programs, and significant resources to combat HIV/AIDS have been allocated, resulting in increased government infrastructure and capacity.3,4 Many successes have occurred since 2003; however, new challenges are emerging, and many previously identified challenges remain and continue to evolve. Although the research effort into properly understanding HIV/AIDS in China continues to expand, it is necessary to translate scientific findings into public health programs, which can be implemented nationwide. China does not yet have the luxury of complacency in its response to HIV/AIDS. This special edition of the AIDS Journal of Acquired Immune Deficiency Syndromes presents research into these new and continuing AIDS challenges. New HIV/AIDS challenges emerging in China include transition from previously blood-driven HIV epidemic to now sex-driven HIV epidemic,3,5 the expanding epidemic among men who have sex with men (MSM),6,7 increasing drug resistance to antiretroviral therapy among new infections,8 the fast changing risk behaviors of high-risk populations,9,10 preventing mother-to-child transmission,11 and the potential for the HIV and tuberculosis (TB) epidemics to merge.12 Among the new HIV/AIDS challenges emerging in China, the expanding epidemic among MSM is undoubtedly the gravest of these new challenges regarding transmission of HIV.6,7,13 The number of MSM in China is considerable, and a large proportion of them also have unprotected sex with women; therefore, significant subgroups of MSM are a bridging group to heterosexual women who are presumed to be low risk. Several articles documenting HIV prevalence, risk behaviors, stigma, and a pilot program to increase condom use and HIV testing are presented here.13–15 Chengdu City, the capital city of Sichuan province, with a large population of MSM, seems to be an important city in the emerging MSM epidemic due to it attracting large numbers of domestic migrants and being a major stop on the heroin trafficking route through China. Two articles presented here investigating HIV/sexually transmitted disease prevalence and sexual risk behaviors and stigma in Chengdu found a HIV,herpes simplex virus-2, and syphilis prevalence rate of 9.1%, 24.7%, and 28.1%, respectively, and low condom use rates varying by partner type: 17.8% for steady female partners and 38.6% for casual male partners.7,15 Stigma and discrimination against HIV/sexually transmitted disease infection and homosexual behaviors were found to be significant barriers to HIV testing and treatment.15 In a study of nearly 5000 MSM in low prevalence regions of China, HIV prevalence was 2.9% and syphilis was 9.8%.13 Encouragingly a trial peer-driven behavioral intervention to increase condom use and HIV testing among MSM in Anhui province significantly increased HIV testing from 10% at baseline to 52.4% postintervention, although the increase in condom use was not as great (55.3% vs. 65.2%), and it was unsuccessful at reducing the number of sexual partners reported.14 The internet has revolutionized MSM interaction in China, and the full import of this is only beginning to be understood by public health professionals. An investigation into HIV prevalence, sexual risk behaviors, and internet use by MSM in Beijing and Urumqi is From the *National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China; and †Chinese Center for Disease Control and Prevention, Beijing, China. Preparation of the article was partly supported by the Multidisciplinary HIV and tuberculosis Implementation Sciences Training in China with the National Institutes of Health Research Grant number of 2U2RTW006918-06 funded by the Fogarty International Center, National Institute on Drug Abuse and the National Institute of Mental Health. Correspondence to: Yu Wang, MD, PhD, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing 102206, China (e-mail: [email protected]). Copyright Ó 2010 by Lippincott Williams & Wilkins J Acquir Immune Defic Syndr Volume 53, Supplement 1, February 1, 2010 www.jaids.com | S1 Introduction J Acquir Immune Defic Syndr Volume 53, Supplement 1, February 1, 2010 an important contribution to understanding the significance of of quality of life compared with child from non–HIV-affected the internet as a sex partner seeking venue.6 Results indicate families.17,21 China now needs to expand on the free schooling that for MSM who use the internet, the internet was by far the offered through the 4 Free’s and 1 Care program to provide most popular venue to find a sexual partner with 82% of adequate support to the gradually increasing numbers of participants using it to find sex partners, the next most popular children affected by the epidemic.1–3 venue, cafes and bars, were only used by 15% of participants.6 The sex industry in China is massive and varied. The implications of this are that outreach activities using Although much work has been done to improve condom use traditional venues will not reach MSM who use the internet. rates among female sex workers (FSWs), as research presented The sexual and other risk behaviors of MSM in China have here shows, consistent condom use with clients remains still not been comprehensively described, and it is anticipated inadequate (58% in the past week), and FSWs are also at risk that they will play a crucial role in the further transition of from regular and nonregular noncommercial sexual partners China’s epidemic from being driven by injection drug use to where condom use rates are usually much lower.22 Un- sexual intercourse; however, the research presented here help doubtedly, efforts targeting FSWs to increase condom use shed light on this vulnerable, and important, risk group. must continue, but as research from migrant miners in Yunnan Regarding the treatment of HIV, the most concerning shows, where 72% of miners who had ever patronized a FSW emerging challenge is expected to be increased future had never used a condom with them, efforts must now be made transmission of drug-resistant strains of HIV. In a sample of to educate male clients of FSWs on the importance of condom nearly 700 newly reported HIV infections from a variety of use.18 In addition, efforts to develop a microbicide, the use of transmission modes in 2004—2005, the prevalence of HIV which is completely controlled by the female, must continue.23 drug-resistant strains was low (3.8%); however, an increase in Encouragingly, hypothetical acceptability of microbicides the transmission of high-level drug resistance was found.8 among FSWs and their male clients in a high HIV prevalence With the increase in sexual transmission of HIV and the region of China seems to be high, however, caution must be majority of HIV-positive people living in China’s countryside, taken if microbicides are brought to market to ensure they are preventing mother-to-child transmission will become more not used as a substitute to condom use.23 important over time. A trial intervention in rural Yunnan to Research instruments are critical to ensuring the prevent mother-to-child transmission, the province worst quality of data collected. Information on the validity of the affected by HIV, had only a 1% seroconversion rate 18 Mandarin versions of the fifth English version of the Addiction months postdelivery and had a 96.3% survival 1 year after Severity Index and the PedsQL (pediatric quality of life) birth.11 Scale-up of the program nationwide should be feasible. are presented.19 China has a high burden of TB, and there is concern Finally, this special edition also includes 2 important that TB and HIV epidemics could merge. Research in articles documenting, in English, for the first time using Guangxi, a high TB and HIV prevalence province, found government data, a comprehensive history of the epidemic in HIV prevalence was higher among TB patients than among the Yunnan,10 the epicenter of China’s HIV/AIDS epidemic; and general population,12 therefore, in selected areas of China, a thorough description of HIV prevalence among affected programs to address TB/HIV coinfection are needed. groups in Henan,9 the province most affected by unsafe Continuing challenges include rural blood supply commercial blood collection. The epidemic in Yunnan has safety,16 providing appropriate support for children affected undergone significant transformation since first being identi- by HIV/AIDS,17 preventing further spread among female sex fied among injection drug users in 1989. By 2007, a total of workers, the role migrant workers play in the epidemic,18 57,325 cases of HIV had been reported, and transmission accessing difficult to reach high-risk populations, and having has slowly evolved from injecting drug use long being China-appropriate research tools.19–21 predominant to sexual transmission in 2007 becoming the All HIV infections are tragic, and an especially tragic most common transmission route. The sociodemographic episode of the HIV epidemic in China was the infection of characteristics of people infected have changed with the share large numbers of rural commercial plasma donors in the early of rural infections decreasing dramatically, and the age range to mid-1990s through unsafe plasma collection practices.9 of infected people continues to increase as does the proportion Because commercial plasma donation was outlawed in 1996, of females. The early stages of the epidemic overwhelmingly significant efforts have been made to increase the safety of affected ethnic minorities, but in 2005, the Han ethnic the blood supply process, especially in rural China.
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