- Email: [email protected]
AIDS in China
p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 2 6 6 e2 6 8
available at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Minisymposium
Recapturing public health sciences for HIV/AIDS in China K.-L. Zhang a,*, J.-S. Zhou b a
Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College, Beijing 100005, China b Sichuan Provincial Centre for Disease Control and Prevention, Chengdu, China
article info
summary
Article history:
In recent years, human immunodeficiency virus (HIV) has spread from high-risk groups to
Accepted 24 January 2011
the general population in China. Scientific interpretation of HIV figures, prevalence and
Available online 21 March 2011
proportion vs incidence is displayed to correctly guide politicians and lay people in understanding the situation. Although behaviour-focused studies have been conducted in
Keywords:
China, many have focused on ‘scientific’ issues, with limited attention given to human
HIV
dimensions or contexts. An evidence-based public health approach, with strict evaluation
Prevention
in terms of cost-effectiveness and behavioural outcomes, needs to be developed, together
Policy
with activity to encourage decentralization and community engagement of programmes.
Public health
Policies and strategies on HIV prevention and control need to be mindful of Chinese culture
China
and reality, including the expansion of screening and surveillance. ª 2011 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Data gathered from sentinel surveillance programmes and case reporting systems across China showed an estimated number of 700,000 people with human immunodeficiency virus (HIV) in September 2009. The cumulative number of reported cases of HIV was 316,000, including 100,200 cases with acquired immunodeficiency syndrome (AIDS) and 48,600 recorded deaths. These figures were in agreement with the Joint Assessment of HIV/AIDS Prevention, Treatment and Care.1 This assessment found that the overall rate of HIV infection in China was 0.05%, which is amongst the lowest in the world. However, recognizing and admitting this fact has long been a challenge for both international and domestic experts. With large numbers of people with high-risk behaviours in China, there had been considerable suspicion that the real figures were underestimates. In the early stages of the epidemic, both the Chinese Government and lay people underestimated the seriousness of the disease, and professionals often overestimated the number of cases of HIV in
China in order to promote the profile of the disease and to advocate its seriousness among people from all walks of life. Prevalence data were used to show the increase in the number of cases of HIV, suggesting that the results could be double among groups with high-risk behaviours. Despite the fact that the overall prevalence of HIV in China is low, high infection rates have been found in specific subpopulations. Data from a national survey showed that 4.9% of cases were amongst men who have sex with men (MSM).2 The average prevalence of HIV among commercial sex workers from the national sentinel surveillance data has increased, with the highest rates close to 10% in several sites. Among intravenous drug users, the HIV-positive rate was 7% in 2007 (personal communication with key personnel at the Chinese Centre for Disease Control). Whilst the epidemic continued to spread, the rate of increase was slowing down.3,4 Sexual transmission was becoming the major mode for the spread of HIV in China, with 40.6% of reported cases in 2009
* Corresponding author. E-mail address: [email protected] (K.-L. Zhang). 0033-3506/$ e see front matter ª 2011 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2011.01.008
p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 2 6 6 e2 6 8
being infected via heterosexual transmission. The geographic distribution of HIV in the country had been highly varied, with the majority of cases seen in five out of 32 provinces/autonomous regions. The epidemic continued to be driven by high-risk behaviour within particular subpopulations.1 An additional contributory factor in the spread of disease during the 1990s was illegal blood donation in some of the provinces. This caused unexpected localized epidemics, but the situation was alleviated through a harsh intervention programme and regulations issued by both central and local governments.1 Economic reform and the opening up policy in the past three decades led to dramatic changes in the social structure of the country and sexual freedom, contributing to the resurgence of commercial sex and tolerance of multiple sex partners. Injecting drug use was once the main source of HIV infection, but this was gradually replaced by sexual transmission. Individuals’ behavioural factors contributed significantly to the high risk of an HIV epidemic, with particularly high prevalence of high-risk behaviours among some subpopulations and locations. For example, a nationwide survey which involved 61 cities found that more than 10% of MSM were HIV positive in some large cities in South West China.5 Other surveys found that more than 1% of the general population was infected with HIV in some parts of Xinjiang autonomous region, Yunnan Province and Sichuan Province (personal communication with key personnel at Chinese Centre for Disease Control), suggesting that ethnicity played a role in the epidemic. There is increasing recognition that innovative, targeted- or evidencebased public health interventions are needed to reduce the risk of HIV transmission and the spread of AIDS within a large, ethnically diverse, mobile population which is engaged in high-risk sexual behaviour. Factors such as culture, ethnicity and attitudes towards HIV and AIDS (e.g. negligence, lack of awareness, carelessness) need to be highlighted, with stigma and discrimination continuing to be problematic. China has scaled up its HIV control efforts since 2004. Top leaders from the central government have shown strong political willingness to stop the spread of AIDS.6 Certain progress has been made in improving the utilization of prevention services by commercial sex workers. However, factors such as low condom use (due to clients willing to pay a high price), high prevalence of sexually transmitted diseases and drug use need to be studied continuously to generate evidence-based data. At the end of September 2009, there were 647 methadone maintenance treatment (MMT) clinics in China, and approximately 227,000 drug users were receiving treatment. It was estimated that the harm-reduction approach of MMT resulted in approximately 3400 fewer cases of HIV per year. Currently, 75,000 people with HIV are engaged in the National Free Antiretroviral Treatment Programme. This programme has reduced mortality among adult AIDS patients to rates similar to those of other low- or medium-income countries. Nevertheless, there is a cumulative immunological treatment failure rate of 50% after 5 years of treatment due to limited availability of second-line regimens. Although behaviour-focused studies have been conducted in China, many have focused on ‘scientific’ issues,7 with limited attention given to human dimensions or contexts. An evidence-based public health approach, with strict evaluation
267
in terms of cost-effectiveness and behavioural outcomes, needs to be developed, together with activity to encourage decentralization and community engagement of programmes. Awareness of AIDS and HIV still needs to be raised among the general population. Policies and strategies on HIV prevention and control, including screening and surveillance programmes, have been established. However, they need to be more rooted in Chinese culture and the reality of the target audience. Some HIVpositive patients were unaware of their HIV status, and this is because of the negative outcomes generated from discrimination and stigmatization. Due to the limitations of voluntary counselling and testing services, provider-initiated HIV testing and counselling (PITC) was introduced in China in recent years; however, careful implementation and evaluation of this new scheme are required and should be mindful of Chinese culture. Potential difficulties in the promotion of PITC have already been identified, including the lack of capacity, especially in rural and remote areas. Factors related to ineffective approaches to the routine provision of services in some areas, as well as financial problems related to payment, unsatisfactory antiretroviral therapy and shortage of secondline regimens and ethical implications, should be further discussed and resolved. More pilot studies should be conducted in different situations to identify better solutions. It is probably time to review the existing policies and actions related to HIV/AIDS. Whilst large efforts have been made, it remains uncertain whether they were cost-effective. Approaches to prevention and intervention should follow the principles of public health sciences. With constant improvement in public health systems and healthcare reforms in China,8 national programmes on HIV prevention and treatment should be more integrated with ‘community-based’ responses to other diseases. In this way, financial, professional and technical integration will make the efforts more effective and affordable.
Ethical approval None declared.
Funding None declared.
Competing interests None declared.
references
1. State Council AIDS Working Committee Office, UN Theme Group on AIDS in China. A joint assessment of HIV/AIDS prevention, treatment and care in China (2007). Beijing: State Council AIDS Working Committee Office; 2007. 2. Lau JTF, Lin C, Hao C, Wu X, Gu J. Public health challenges of the emerging HIV epidemic among men who have sex with men in China. Public Health 2011;125. 3. Jiang Y, Wang M, Ni M, Duan S, Wang Y, Feng J, et al. HIV-1 incidence estimates using IgG-capture BED-enzyme
268
p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 2 6 6 e2 6 8
immunoassay from surveillance sites of injection drug users in three cities of China. AIDS 2007;21Suppl. 8:S47e51. 4. Wei X, Liu W, Li F, Wang X, Zheng WW. Detection of HIV incidence using BED capture enzyme immunoassay at a surveillance sentinel site of injection drug users in Guangxi. Zhonghua Yu Fang Yi Xue Za Zhi 2009;43:1096e9 [in Chinese]. 5. Ministry of Health, People’s Republic of China/UNAIDS/WHO. 2009 estimates for the HIV/AIDS epidemic in China. Beijing; 2010.
6. Wu Z, Sullivan SG, Wang Y, Rotheram-Borus MJ, Detels R. Evolution of China’s response to HIV/AIDS. Lancet 2007;369: 679e90. 7. Zhao X, Guo P, Li X. Meta analysis of effects of interventions for preventing HIV/AIDS among MSM in China. Mod Prev Med 2010; 37:19 [in Chinese]. 8. Dong Z, Phillips MR. Evolution of China’s health-care system. Lancet 2008;372:1715e6.
available at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Minisymposium
Recapturing public health sciences for HIV/AIDS in China K.-L. Zhang a,*, J.-S. Zhou b a
Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College, Beijing 100005, China b Sichuan Provincial Centre for Disease Control and Prevention, Chengdu, China
article info
summary
Article history:
In recent years, human immunodeficiency virus (HIV) has spread from high-risk groups to
Accepted 24 January 2011
the general population in China. Scientific interpretation of HIV figures, prevalence and
Available online 21 March 2011
proportion vs incidence is displayed to correctly guide politicians and lay people in understanding the situation. Although behaviour-focused studies have been conducted in
Keywords:
China, many have focused on ‘scientific’ issues, with limited attention given to human
HIV
dimensions or contexts. An evidence-based public health approach, with strict evaluation
Prevention
in terms of cost-effectiveness and behavioural outcomes, needs to be developed, together
Policy
with activity to encourage decentralization and community engagement of programmes.
Public health
Policies and strategies on HIV prevention and control need to be mindful of Chinese culture
China
and reality, including the expansion of screening and surveillance. ª 2011 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Data gathered from sentinel surveillance programmes and case reporting systems across China showed an estimated number of 700,000 people with human immunodeficiency virus (HIV) in September 2009. The cumulative number of reported cases of HIV was 316,000, including 100,200 cases with acquired immunodeficiency syndrome (AIDS) and 48,600 recorded deaths. These figures were in agreement with the Joint Assessment of HIV/AIDS Prevention, Treatment and Care.1 This assessment found that the overall rate of HIV infection in China was 0.05%, which is amongst the lowest in the world. However, recognizing and admitting this fact has long been a challenge for both international and domestic experts. With large numbers of people with high-risk behaviours in China, there had been considerable suspicion that the real figures were underestimates. In the early stages of the epidemic, both the Chinese Government and lay people underestimated the seriousness of the disease, and professionals often overestimated the number of cases of HIV in
China in order to promote the profile of the disease and to advocate its seriousness among people from all walks of life. Prevalence data were used to show the increase in the number of cases of HIV, suggesting that the results could be double among groups with high-risk behaviours. Despite the fact that the overall prevalence of HIV in China is low, high infection rates have been found in specific subpopulations. Data from a national survey showed that 4.9% of cases were amongst men who have sex with men (MSM).2 The average prevalence of HIV among commercial sex workers from the national sentinel surveillance data has increased, with the highest rates close to 10% in several sites. Among intravenous drug users, the HIV-positive rate was 7% in 2007 (personal communication with key personnel at the Chinese Centre for Disease Control). Whilst the epidemic continued to spread, the rate of increase was slowing down.3,4 Sexual transmission was becoming the major mode for the spread of HIV in China, with 40.6% of reported cases in 2009
* Corresponding author. E-mail address: [email protected] (K.-L. Zhang). 0033-3506/$ e see front matter ª 2011 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2011.01.008
p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 2 6 6 e2 6 8
being infected via heterosexual transmission. The geographic distribution of HIV in the country had been highly varied, with the majority of cases seen in five out of 32 provinces/autonomous regions. The epidemic continued to be driven by high-risk behaviour within particular subpopulations.1 An additional contributory factor in the spread of disease during the 1990s was illegal blood donation in some of the provinces. This caused unexpected localized epidemics, but the situation was alleviated through a harsh intervention programme and regulations issued by both central and local governments.1 Economic reform and the opening up policy in the past three decades led to dramatic changes in the social structure of the country and sexual freedom, contributing to the resurgence of commercial sex and tolerance of multiple sex partners. Injecting drug use was once the main source of HIV infection, but this was gradually replaced by sexual transmission. Individuals’ behavioural factors contributed significantly to the high risk of an HIV epidemic, with particularly high prevalence of high-risk behaviours among some subpopulations and locations. For example, a nationwide survey which involved 61 cities found that more than 10% of MSM were HIV positive in some large cities in South West China.5 Other surveys found that more than 1% of the general population was infected with HIV in some parts of Xinjiang autonomous region, Yunnan Province and Sichuan Province (personal communication with key personnel at Chinese Centre for Disease Control), suggesting that ethnicity played a role in the epidemic. There is increasing recognition that innovative, targeted- or evidencebased public health interventions are needed to reduce the risk of HIV transmission and the spread of AIDS within a large, ethnically diverse, mobile population which is engaged in high-risk sexual behaviour. Factors such as culture, ethnicity and attitudes towards HIV and AIDS (e.g. negligence, lack of awareness, carelessness) need to be highlighted, with stigma and discrimination continuing to be problematic. China has scaled up its HIV control efforts since 2004. Top leaders from the central government have shown strong political willingness to stop the spread of AIDS.6 Certain progress has been made in improving the utilization of prevention services by commercial sex workers. However, factors such as low condom use (due to clients willing to pay a high price), high prevalence of sexually transmitted diseases and drug use need to be studied continuously to generate evidence-based data. At the end of September 2009, there were 647 methadone maintenance treatment (MMT) clinics in China, and approximately 227,000 drug users were receiving treatment. It was estimated that the harm-reduction approach of MMT resulted in approximately 3400 fewer cases of HIV per year. Currently, 75,000 people with HIV are engaged in the National Free Antiretroviral Treatment Programme. This programme has reduced mortality among adult AIDS patients to rates similar to those of other low- or medium-income countries. Nevertheless, there is a cumulative immunological treatment failure rate of 50% after 5 years of treatment due to limited availability of second-line regimens. Although behaviour-focused studies have been conducted in China, many have focused on ‘scientific’ issues,7 with limited attention given to human dimensions or contexts. An evidence-based public health approach, with strict evaluation
267
in terms of cost-effectiveness and behavioural outcomes, needs to be developed, together with activity to encourage decentralization and community engagement of programmes. Awareness of AIDS and HIV still needs to be raised among the general population. Policies and strategies on HIV prevention and control, including screening and surveillance programmes, have been established. However, they need to be more rooted in Chinese culture and the reality of the target audience. Some HIVpositive patients were unaware of their HIV status, and this is because of the negative outcomes generated from discrimination and stigmatization. Due to the limitations of voluntary counselling and testing services, provider-initiated HIV testing and counselling (PITC) was introduced in China in recent years; however, careful implementation and evaluation of this new scheme are required and should be mindful of Chinese culture. Potential difficulties in the promotion of PITC have already been identified, including the lack of capacity, especially in rural and remote areas. Factors related to ineffective approaches to the routine provision of services in some areas, as well as financial problems related to payment, unsatisfactory antiretroviral therapy and shortage of secondline regimens and ethical implications, should be further discussed and resolved. More pilot studies should be conducted in different situations to identify better solutions. It is probably time to review the existing policies and actions related to HIV/AIDS. Whilst large efforts have been made, it remains uncertain whether they were cost-effective. Approaches to prevention and intervention should follow the principles of public health sciences. With constant improvement in public health systems and healthcare reforms in China,8 national programmes on HIV prevention and treatment should be more integrated with ‘community-based’ responses to other diseases. In this way, financial, professional and technical integration will make the efforts more effective and affordable.
Ethical approval None declared.
Funding None declared.
Competing interests None declared.
references
1. State Council AIDS Working Committee Office, UN Theme Group on AIDS in China. A joint assessment of HIV/AIDS prevention, treatment and care in China (2007). Beijing: State Council AIDS Working Committee Office; 2007. 2. Lau JTF, Lin C, Hao C, Wu X, Gu J. Public health challenges of the emerging HIV epidemic among men who have sex with men in China. Public Health 2011;125. 3. Jiang Y, Wang M, Ni M, Duan S, Wang Y, Feng J, et al. HIV-1 incidence estimates using IgG-capture BED-enzyme
268
p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 2 6 6 e2 6 8
immunoassay from surveillance sites of injection drug users in three cities of China. AIDS 2007;21Suppl. 8:S47e51. 4. Wei X, Liu W, Li F, Wang X, Zheng WW. Detection of HIV incidence using BED capture enzyme immunoassay at a surveillance sentinel site of injection drug users in Guangxi. Zhonghua Yu Fang Yi Xue Za Zhi 2009;43:1096e9 [in Chinese]. 5. Ministry of Health, People’s Republic of China/UNAIDS/WHO. 2009 estimates for the HIV/AIDS epidemic in China. Beijing; 2010.
6. Wu Z, Sullivan SG, Wang Y, Rotheram-Borus MJ, Detels R. Evolution of China’s response to HIV/AIDS. Lancet 2007;369: 679e90. 7. Zhao X, Guo P, Li X. Meta analysis of effects of interventions for preventing HIV/AIDS among MSM in China. Mod Prev Med 2010; 37:19 [in Chinese]. 8. Dong Z, Phillips MR. Evolution of China’s health-care system. Lancet 2008;372:1715e6.