HIV/AIDS in China and its Implications for Tibetans and Other Minorities

HIV/AIDS in China and its Implications
for Tibetans and Other Minorities
By Spencer Seidman, LCSW

According to a recent report from the China News Monthly, China will have between 600,000 to 1 million HIV positive individuals this year with an annual rate increase of 30%.Zeng Yi, an AIDS researcher at the Chinese Academy of Sciences, reports that:

"If no measures are taken quickly, China will have the most AIDS victims in the world and the spread of AIDS will become a national disaster"1

Only recently has there been any official recognition of the problem; however, a small yet important trickle of documentation has begun to flow out of China regarding the significant HIV prevalence in both the rural and urban areas. Now that HIV is entering into mainstream society, affecting farmers, migrant workers and, those of the new Chinese middle-class (including members of the Peoples Liberation Army), the national press is currently reporting on this critical issue.

HIV/AIDS and Minorities

China has 55 officially recognized nationalities, accounting for about 10% of the nation’s population (presently 1.3 billion people). Yunnan, Sichuan, Gansu and Xinjaing provinces are home to 39 of the minority groups that live in China. Minorities live in the provinces that have high rates of HIV/AIDS such asYunnan and Xinjaing. Yunnan, with 19 minority groups, has the highest reported HIV-rate in China. Although minorities represent only one-tenth of the total population of China, they may suffer from disproportionately high HIV-rates. Should the rate of HIV continue to grow at 30% per year, a significant decrease in minority populations may occur. The focus of HIV/AIDS studies and of journalistic reportage has been on the nature of the problem from a global perspective; studies on individual minority groups in China have been minimal. In many provinces where Tibetans reside there are no HIV testing sites, so only through inference from data in other regions can we predict future trends.

The principal aim of this paper is to examine HIV/AIDS in China first from a global perspective by reviewing current literature; and then to analyze how this data could affect a single minority group, such as the Tibetans.

HIV/AIDS in China

The first case of AIDS reported in China was in 1985. Now the Chinese government estimates that there are 500,000 HIV positive individuals in China. But where did these estimates come from, and how accurate are these figures?

"Chinese experts emphasize that there is no reliable information on how far HIV has actually spread in China. The government estimates that 75% of HIV-infected people in China are intravenous drug users, but many epidemiologists, both foreign and Chinese do not consider this data to be reliable. Surveillance in China focuses on publicly acknowledged high-risk populations such as drug users. But some Chinese officials believe that the numbers of people infected through selling or receiving blood transfusions is much higher than is stated publicly. In addition, China's sex trade, which flourishes even in rural areas, greatly boosts the risk of the rapid spread of HIV beyond current acknowledged high-risk groups such as intravenous drug users. Further complicating the question of how many people in China carry HIV, is China’s 100 million migrant workers, a group that is relatively difficult to study. The Shanxi Province Epidemiological Station reported in an October 2000 article that of the 176 HIV cases reported (very likely only a very small fraction of the actual number), two-thirds were migrant workers. Nearly one-half of the migrant workers were from outside Shanxi, and five percent of the HIV-infected persons were paid blood donors. As a result, some Chinese experts now estimate the number of Chinese infected with HIV to be as high as one million, with the total figure increasing by about 30% annually. Aside from Yunnan Province, the "birthplace" of AIDS in China, the regions of Henan, Sichuan, Xinjiang, and Guangx i have been especially hard hit with HIV/AIDS. The sexual transmission of HIV seems already well established in Yunnan, and perhaps soon will become prominent in some of the southeast coastal provinces that suffer high Sexually Transmitted Disease (STD) rates. (Yunnan Province is reported to be home to approximately half of China's HIV-infected population, and 44% of its AIDS cases. But Yunnan has the most monitoring stations, so it is possible that its high HIV ranking is also related to its relatively effective monitoring, in addition to the relative seriousness of the HIV problem.)"2

Public Policy

The spread of HIV/AIDS in China has some unique qualities. This pertains to public policy for marginalized groups (prostitutes, IV drug users, and homosexuals) and social/cultural feelings about an illness of this nature and the groups afflicted.

Regarding such problems and policies Chinese sources have stated the following:

"Many experts call for continued, broad education on AIDS prevention, but economic and social hurdles constantly threaten to frustrate national efforts to curb the spread of AIDS. According to a memo written by Zeng Yi, China spent only US$2.75 million between 1996-97 on AIDS prevention, compared with US$4.5 million in Vietnam and US$74 million in Thailand. A more tricky issue comes from social recognition of some sensitive, yet widely used measures to prevent HIV infection, such as education for high-risk groups and the distribution of condoms. Controversy has never ceased even among experts over whether China should do these things, or even formally recognize high-risk groups, such as prostitutes, long-distance truck drivers, soldiers and drug abusers, Zeng said. Zeng admitted it would conflict with China's traditional morality. But people will have to face up to it and make choices because an effective and economical cure will not be available for quite a long time."3

1) Reporting of HIV/AIDS Cases:

On December 1, 1999, China News Services reported: "Some government leaders in China are delaying or concealing from higher authorities information reports on the AIDS epidemic." It also mentioned Yin Dakui, the Vice Minister of Public Health, and his allegation that some government officials are hindering AIDS prevention and treatment efforts. This came in the wake of a recent Ministry of Health report that the number of HIV cases rose 33% per year since the first three-quarters of 1999. Yin’s comments were also made on the day that the nation’s first televised condom commercial was pulled from the China Central Television Channel 1 network -- a broadcast that reaches hundreds of millions of people nationwide.4

2) Illegal Blood Collection

Surveys show that in Western countries, intravenous drug use and sex are the principal ways in which HIV is spread. In China however the problem of HIV infection extends to the illegal collection of blood. According to various reports, from the 1980s to the mid-1990s many farmers earned their living by selling blood. Each "bloodhead" or xietou, a person who organizes a group of such donors, leads several dozen people to the blood collection center. When the blood collection truck arrives, the farmers roll up their sleeves. But the needles are not sterilized: a syringe used on one person was then inserted directly into the vein of another.

The government has repeatedly forbidden the illegal collection of blood, but ‘donors’, who are determined to escape poverty, and bloodheads, who continue to chase after their profits, have continued the practice in certain areas. A People's Daily reporter who visited an underground blood collection station eventually had to hire a bodyguard because he feared revenge from the bloodhead organization. According to some reports, certain few government officials are also involved in the bloodhead organization.5

3) IV Drug Use

Chinese law is clear regarding the possession of syringes:

"According to Chinese law a person may be arrested for drug abuse if carrying an injection needle. Thus, fear of arrest may discourage many IV drug users from participating in needle exchange programs or carrying clean needles themselves (instead using those provided by the drug sellers). This creates greater risk for HIV transmission, according to drug abuse experts."6

4) Prostitution

Prostitution is a widespread phenomenon in China and one largely controlled by organized crime. Women are regularly kidnapped and forced into prostitution: they are taken to remote areas, where they have no resources of their own, and where they become slaves to the pimps who abducted them. The outright selling of women as wives is also common, especially in areas that have higher proportions of men to women. For some poor women, who are not professional prostitutes, prostitution has become a way to supplement their income. Since these women are scared and marginalized, they do not receive proper health care, and they unwillingly help the spread of sexually transmitted diseases.

The problem of prostitution in China is a complex one, and one with no simple solution:

"In China, Wang Yanguang argued, prostitution is widespread and takes many different forms. Neither the "strike hard" approach of the Chinese police nor the "red light district" strategy suggested by some Chinese scholars can be successful," he [Wang] believes. Wang wrote: "The rapid growth of China's sex industry is not simply a matter of the moral fall of those women who sell themselves. The context of this problem includes rapid economic development, a growing gap between rich and poor both in cities and in the countryside, unemployment, poverty and relative poverty, and a big buyer's market. Under these conditions, there are no simple solutions that could make the sex trade disappear in a short time. The only solution is for the health authorities and public security to work together to see that prostitutes use condoms ... and get regular medical care. Only in this way can we ensure that the chances of HIV being transmitted by prostitutes can be reduced." 7

5) Homosexuality

Attitudes about homosexuality in China have not helped the situation:

"A public health official told a U.S. Embassy Environment, Science and Technology section officer (ESTOFF) that the government "allows us to do health work with homosexuals who have HIV but the government does not want us to report back what we are doing." The official also told ESTOFF: "most Chinese homosexuals do not know that some homosexual behaviors (anal sex, large numbers of sex partners) put them at high risk for HIV/AIDS."8

6) Changes in Health Care Policy

Since the development of a market economy, health care has declined significantly. Many people cannot afford to go to doctors and hospitals and there have been large reductions in the Health Ministry’s budget. This has led to an increase of communicable diseases, such as syphilis.

"In addition, sexually transmitted diseases (STD’s) and especially syphilis greatly increase the likelihood of transmission of HIV through sexual intercourse. And STD infections in China continue to grow at roughly 30% each year -- a long-term trend. (STD infections climbed 32% nationally in 1999, according to the Chinese National Center for STD and Leprosy Control.) Mother-to-child congenital syphilis rates, meanwhile, doubled during 1999. Shanghai, Zhejiang, Beijing, Jiangsu, Guangdong and Hainan report the highest incidence of STD's, although Shanghai, Guangdong and Hainan reported increases of 10% or less."9

Infectious diseases are common in China: 250,000 people per year die from Tuberculosis, and 40% of the population is positive for TB. HIV can appear to be a small problem in comparison. But AIDS patients are magnets for TB because they have impaired immune systems and -- as has been reported for other countries -- AIDS will certainly exacerbate the present TB problem.10

7) Poverty

The December 8th edition of the People’s Daily East China News pointed to the lax attitude of local government officials in Henan, the poverty of farmers, and the greed of the illegal blood-collection center operators as key reasons why the widespread and illegal blood selling in eastern and southern Henan Province have continued for such a long time - resulting in many HIV infections. The article also accused some government officials of helping to set up some of the illegal blood banks. The Daily did not spare Central Government officials. It noted that of the 86 countries which, like China, had first discovered HIV within their borders in 1985, about one-third had established HIV/AIDS prevention organizations within 18 months of the discovery. China, however, waited 13 years (!) -- finally establishing its first AIDS Prevention and Control Center in 1998. The article concluded: "We need to know how this happened, for the sake of our health and our future."11

HIV/AIDS and Tibetans

Where do Tibetans and other minorities fit into this picture?

China’s minorities reside in some of the poorest and most rural areas in China: places where HIV/AIDS reaches its highest rates. If HIV/AIDS goes unchecked, these minority groups may be devastated by AIDS and by other infectious diseases. These groups have survived in China for over a millennium -- and now their population could be significantly decreased in a mere twenty years.

Tibetans are one of the larger minorities in China. The official Chinese figure for Tibetans in China is 4,196,000 (cited in the Renmin Ribao on April 26, 1991). According the 1990 census, Tibetans reside in the Tibetan Autonomous Region (TAR), Sichuan, Qinghai, Gansu and Yunnan Province. It is estimated that there are 2,096,300 Tibetans in the TAR. In addition, some 400,000 Tibetans are scattered in other Chinese provinces, outside Tibet.

HIV poses a threat to Tibetans both inside and outside the TAR. No one knows how many people have active AIDS or are HIV positive in the TAR, Gansu, and Qinghai, due to the lack of testing sites in these areas. What is known is that Yunnan has the largest reported AIDS rate in China, and that Sichuan also has a significant HIV positive population; both provinces have large Tibetan populations.

The principal risk factors for Tibetans are:

A lack of educational HIV/AIDS-prevention programs.
A tendency to reside in poor rural areas. The economic situation in such areas encourages people to engage in illegal blood sales, and in prostitution, in order to earn extra income.
A high rate of poverty, which has a demoralizing effect that can in turn lead to intravenous drug use.
A high risk of HIV-contraction through blood transfusions and other medical procedures if universal precautions are not followed.

These risk factors pose greater dangers for Tibetans living outside the TAR, because they live in what are considered high-risk areas, with their associated economic problems. Residents of the TAR are at a slightly lower risk-level due only to their physical isolation and to a lack of illegal blood banks, but the residents are increasingly affected by migrant populations, which have been entering the TAR in greater numbers for the last ten years.

The Numbers

According to UN figures (based on testing-site information estimates by the Chinese Academy of Preventive Medicine), Yunnan Province had a 3.5% HIV-rate for prostitutes tested, and Sichuan had a less than 1% rate. In Xinjaing, which is north of Tibet, it was found that 5 out of 13 prostitutes tested positive in 1998.12

According to the UNAIDS/WHO Epidemiological Fact Sheet:

"Xinjaing has a 44% to 85% HIV prevalence rate among Intravenous Drug Users (IDU)."13

"Most of China's AIDS victims were drug users in the Yunnan province. After 1994, AIDS spread from Yunnan to the rest of the country. A Qinghai province report in June 1998 report found that in four short years, AIDS had spread to 31 provinces, cities and self-autonomous regions in China."14

Health Care in the Tibetan Autonomous Region

"During a November 2000 visit to Shannan, Lhasa and Linzhi prefectures in the Tibet Autonomous Region (TAR), a U.S. Embassy Beijing Environment, Science and Technology Counselor met with regional health officials to discuss the key health policy challenges facing Tibet. The officials explained that despite extensive central government subsidies, the region's health care infrastructure still significantly lags behind the rest of China -- reflecting the relatively backward state of general economic development, as well as the difficulty in supplying health services to Tibet's far-flung and sparse population. Certain endemic diseases, including tuberculosis, iodine deficiency, and Kashin-Beck Disease, are prevalent at unusually high rates in Tibet; and [in] certain areas nutrition [is] still a serious problem. Hepatitis B is also a major challenge, but on the bright side HIV/AIDS has not yet had a measurable impact on the region (although no one is currently tracking the disease there)."15

The U.S Embassy report continues to state:

"Other poor regions of China without AIDS monitoring programs have discovered, once testing was commenced, significant populations of HIV-positive individuals (the AIDS patients having been treated only for the various syndromes related to the underlying infection). When AIDS is officially confirmed as having arrived in Tibet, it is quite likely that the largest population of infected persons will be found first in Linzhi Prefecture, due to its border with heavily-infected Yunnan Province and its relatively large floating population, including prostitutes and soldiers..."16

"HIV infections contracted via paid blood donors could also become a problem in the future, since the TAR has not yet succeeded in establishing a contributions-based blood bank system (the government has recently budgeted 9.5 million RMB to address this problem). While paid blood donors exist, the "market" for blood and blood products is not well developed, so the most common (and relatively safe) practice is still to recruit blood donors from within a family or work unit in time of need. Genetic research based on blood sampling is not common in Tibet, and no such research by foreigners is currently taking place, say health officials."17

Conclusion

Zheng Wenkang, the Chinese Minister of Health effectively sums up the complexities of the HIV/AIDS situation in China.

"AIDS is not a simply a public health problem. It is rather a complex social problem. All of society must get involved and share responsibility for actively working together to solve this problem. Under the leadership of the Communist Party Central Committee and the State Council and each level of Party and government organization, we must not miss any opportunity to implement all HIV prevention and control policies and measures. We must strive to build and complete this long-term social system project so as to reduce to the greatest extent possible the harm that HIV causes to the people and society. At present, HIV is still at a low level of contagion. Prevention and control are most suitable for this period. This is our last chance to beat the epidemic."18

The above quote is a rare example of a high level official publicly recognizing the HIV problem. If public policy is not implemented, however - and that includes HIV/AIDS education, combating of organized crime by stopping the sex slave trade, drug dealers, and the blood pimps -- then HIV/AIDS will continue unabated. Reform is needed to allow China’s minorities to dictate their own future. But unfortunately, this is politically difficult for a bureaucratic centralized government.

Forums already exist, however, that can lead to policy reforms. The People’s Congress includes representatives from all of China’s minority groups. Also of late there has been significant progress in collaborative projects with international NGO's related to HIV/AIDS prevention throughout China. Several of these projects are in areas which have high Tibetan and other minority populations.

Tibetans and other minority groups need to set their own health agenda if they wish to help stop the spread of HIV/AIDS. They must put pressure on the Central Government to allow them to educate their own constituencies in HIV/AIDS prevention and to train their physicians in the diagnosis and treatment of HIV/AIDS. China needs to continue to work with international health agencies to construct educational programs targeting: the general population, high-risk groups, and minorities. The training of health care staff in HIV/AIDS prevention, and implementing universal precautions in medical settings is critical in stemming its spread. If these policies are not developed soon, then China’s minorities may indeed become an endangered species.

E-mail: seidman@psychotherapysanfrancisco.com

References

1 "Experts Estimate 600,000-1 Million AIDS Victims in China." People’s Daily, 04 September 2000. Internet Edition
http://english.peopledaily.com.cn/200009/04/eng20000904_49682.htm

2 "AIDS in China: From Drugs to Blood to Sex." U.S. Embassy, Beijing -December 2000.
http://www.usembassy-china.org.cn/english/sandt/hivsextrans.htm, http://www.usembassy-china.org.cn/english/sandt/hivsextrans.htm

3 Sheng, He. "Long Road Ahead in Fight Against AIDS." China Daily, 21 August 2000.

4 "China Officials Hindering AIDS Prevention Efforts." China News Services, 1 December 1999.

5 Hong, Ho. "Can Morality and Justice Serve in the Fight Against AIDS." People’s Daily East China, 8 December 2000

6 "AIDS in China: From Drugs to Blood to Sex." U.S. Embassy, Beijing -December 2000.
http://www.usembassy-china.org.cn/english/sandt/hivsextrans.htm

7 Yuanguang, Wang. "Strategy of Tolerance and HIV/AIDS Prevention in China." . Journal of Medicine and Philosophy, 2000 Feb, 25(1):48-61.

8 "HIV/AIDS in CHINA: A WORLD OF CONTRADICTIONS." U.S Embassy, Bejing -April 1997.
http://www.usembassy-china.org.cn/english/sandt/webads1a.htm

9 "AIDS in China: From Drugs to Blood to Sex." U.S. Embassy, Beijing -December 2000.

10 Xueqin, Jaing "Currents: China’s TB Epidemic-Consuming Problem," Far Eastern Economic Review, 21 December 2000, 84-87.

11 Recent Chinese Reports on HIV/AIDS and Sexually Transmitted Diseases-Summery Title-"Media Takes the Gloves Off in Criticizing HIV Policies." U.S. Embassy, Beijing , March 2001, Source - People’s Daily East China News, December 15, 2000.
http://www.usembassy-china.org.cn/english/sandt/hivartic.html

12 "Current Status of HIV in China:by Dec. 1999", UN in China Website
http://www.unchina.org/unaids/ekey3right1.html

13 "Epidemiological Fact Sheet on HIV/AIDS and Sexually Transmitted Infections"-China-2000 Update-UNAIDS and World Health Organization -2000

14 "Experts Estimate 600,000-1 Million AIDs Victims in China." People’s Daily, 04 September 2000. Internet Edition
http://english.peopledaily.com.cn/200009/04/eng20000904_49682.html

15 "Health Policy Challenges In The Tibet Autonomous Region." U.S Embassy, Beijing December 2000

16 "Health Policy Challenges In The Tibet Autonomous Region." U.S Embassy, Beijing December 2000

17 "Health Policy Challenges In The Tibet Autonomous Region." U.S Embassy, Beijing December 2000

18 Xiwen, Zheng "Epidemiologic study and prevention of AIDS in China." Chung-Hua Liu Hsing Ping Hsueh Tsa Chih Chinese Journal of Epidemiology, 1999 Jun, 20(3):131-4.

HIV and AIDS in China
Reference Information

Excellent Websites with resources:

China AIDS Survey
Also includes a a glossary of HIV/AIDS terms from English to Chinese

China AIDS Info
Excellent updated resource

Hong Kong AIDS Information Network
In English and Chinese

Important Source Documents:

HIV/AIDS: China's Titanic Peril

Locked Doors: The Human Rights of People Living with HIV/AIDS in China

EPIDEMICS and IMPACT of AIDS and STRATEGIES for CONTROL in PR.China
Chinese Center for Disease Control & Prevention National Center for AIDS/STD Control and Prevention. A PDF slide presentation.

Articles which may also include good links to additional source information:

Asian HIV epidemic major threat to global security and economy, says policy thinktank

David Ho to Set up AIDS Prevention & Monitoring Station in Central China
Peopledaily.com Thursday, July 17, 2003

Drug Access
Aaron Diamond AIDS Research Center, China's Yunan Province to Provide Combination Therapy in Country's Largest HIV/AIDS Treatment Program [Oct. 22, 2002]

HIV & AIDS in China
Avert.Org-Good historical review

Organizations:

AIDS Relief Fund For China