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Aids in China: Scrambling to defy a bleak prediction

It is a race against inevitability, the prediction that 10 million people in China will be infected with HIV by the year 2010. “We talk about it like it’s way off into the future but it’s just a few years away,” says Allen Anderson, who has studied the evolution of this disease in China with both fascination and profound sadness.

To thwart HIV’s steady progress, Anderson, a professor at the School of Public and Environmental Affairs, works closely with China on preventative interventions and there is reason to be hopeful: New Chinese leadership is finally willing to confront the problem rather than deny it.

But Anderson admits that he is also worried. The World Health Organization estimates that 840,000 Chinese are currently infected and this is a conservative guess; 1.5 million is probably closer to the truth. The vast majority of those infected have not been tested and, presumably, are getting progressively worse while infecting others.

The story of AIDS in China is the story of sweeping economic and social change, of heroin trafficking and prostitution, of massive migrations from rural areas to big cities. It is also the story of stigma and ignorance, a fatal and familiar combination wherever AIDS takes root.

chinaThe infection first appeared north of the Golden Triangle, the border area of Thailand, Myanmar (formerly known as Burma), and Laos, where vast poppy fields are cultivated for opium, which is processed into heroin. It spread rapidly along this heroin-trafficking route and through China, quickly penetrating all levels of society. Anderson has looked at HIV and its relationship to four major groups: prostitutes, intravenous drug users, health care workers, and the “floating population”—the 120 million Chinese who move from rural to urban areas in search of work.

“The men [in the floating population] leave their families behind,” notes Anderson. “Some are bored and lonely or depressed. They go to prostitutes or they start taking drugs. So you can see the potential for infection is just tremendous.” And because this is an “oscillating” migration—workers travel between work and home for the periodic visit with spouses—the virus is virtually guaranteed to affect a broad geographic range.

Though prostitution is flourishing, the pay is generally low so that sex workers are loathe to spend their meager cash on condoms. Even if they did, observes Anderson, “many of the men don’t care to use condoms with prostitutes. They’re already using them at home with their wives for birth control and figure, ‘I’m out on a fling, so why should I use them now?’”

Slowly, the facts about HIV are making their way to Chinese sex workers in spite of initial opposition from police. “How could we facilitate condom use among prostitutes when prostitution is an offense? That was a major hurdle for us. So there was some initial tension with law enforcement but now everyone sees the gravity of the situation and we’re getting a lot more cooperation. Not that there aren’t problems—prostitution is still a crime and prostitutes are still a cloistered community and hard to reach—but a lot of progress has been made in the last three or four years.”

Intravenous drug use continues to be a sturdy agent of transmission because of widespread trafficking out of the Golden Triangle, through southern China, and up to the coastal area around Guangzhou in the Guangdong province. “There’s a huge law enforcement push in drug interdiction but it’s an uphill battle,” says Anderson. “The southern border is tremendously isolated, rugged, and porous. For all the effort and money that’s been spent, we haven’t made much progress.”

To address the problem of infection and health care workers, Anderson’s group studied hospitals in the Guangxi Zhuang Autonomous Region, specifically in the capital city of Nanning. Researchers were astounded by what they discovered there. “We found a lot of misunderstanding about AIDS among hospital workers, and that includes physicians and nurses,” he recalls. “They had misconceptions about how the infection is transmitted and they had rather loose procedures for infection control. In response, we’ve created a number of interventions to get health care workers up to speed.”

In the process, the goal isn’t only to make a medical impact but a social one, too; with so much misunderstanding about the disease’s transmission, it’s no surprise that AIDS patients are often stigmatized and ostracized. “We want Chinese health care workers to be beacons of education who bring understanding and non-discrimination to their own neighborhoods,” he says.

Most developing countries undergo “epidemiological transition” as the prevailing diseases shift from infectious to chronic disease—in other words, it’s actually a strange sign of progress when malaria and yellow fever are preempted by heart disease and cancer. China, however, is in the unenviable position of experiencing “epidemiological polarization” in which both disease patterns are on the rise: chronic disease in the cities, infectious in the rural areas.

If there is any good news in this bleak picture it is the response of China’s central government. “They’re going the extra mile in offering AZT treatment to anyone who becomes infected with HIV,” Anderson says. “But maybe the most positive sign of change is also the most subtle. It’s the simple recognition of the problem, the willingness to talk about it at the governmental level. And maybe that discussion will filter down and people will become more open and understanding as they get the education they need to prevent this disease.”

Anderson is a researcher, but he is also a man of deep compassion for the people he studies, and he says that his work has changed him at his core. “I’m much more aware now of what it means to be a have-not in this world,” he says. “And there is something wrong when there are drugs available to make AIDS a chronic condition, to extend your life 15 years or more beyond the diagnosis, but you may die in three years if you are poor.It just rips your heart out. It’s just not right. Hopefully, through education and the participation of governmental leaders, and by sending people into the field with a global perspective, we can overcome those inequities.”

Allen F. Anderson is a visiting professor at the School of Public and Environmental Affairs at Indiana University, Bloomington. Anderson has worked on HIV/AIDS transmission and control issues in the People’s Republic of China for over 14 years, serves as an ongoing consultant to the Chinese Foundation for the Prevention of STD & AIDS, Beijing, and has also served as a consultant to the Chinese Ministry of Justice concerning AIDS control in the prison population. Anderson received his Ph.D. in 1984 from Southern Illinois University and a certification in Public Health from the University of North Carolina at Chapel Hill (2004).