While HIV is a type of sexually transmitted infection,[5] the first years of the epidemic in China were dominated by non-sexual transmission routes, particularly among users of intravenous drugs through practices such as needle sharing.[6] By 2005, 50% of new HIV cases were due to sexual transmission,[7] with heterosexual sex gradually becoming the most common means of new infections in the 2000s.[8] New infections among men who have sex with men (MSMs) grew rapidly thereafter, representing 26% of all new cases in 2014, up from 2.5% in 2006.[9] Another major, non-sexual channel of infection was the Plasma Economy of the 1990s, wherein large numbers of blood donors, primarily in poor, rural areas in Henan Province, were infected with HIV as a result of systematically dangerous practices by state and private blood collection clinics.[10]
HIV evolved from the simian immunodeficiency virus (SIV), present in numerous species of primates in West Africa and Central Africa, in the early 20th century. SIV jumped from primates to humans several times, although the primary strain of HIV responsible for the global pandemic, HIV-1 group M, is traceable to the region surrounding Kinshasha,[11] likely having initially crossed from chimpanzees around 1920.[12] From there, it spread to the Caribbean around 1967, proceeding to establish itself in New York City and San Francisco circa 1971 and 1976, respectively.[13]
The US Centers for Disease Control and Prevention (CDC) recognized unusual outbreaks of opportunistic infections among gay men in 1981,[14][15] and the disease was initially referred to as gay-related immune deficiency (GRID), although it was quickly understood to also infect heterosexuals as well.[16] In 1982, the CDC adopted the name "acquired immune deficiency syndrome" (AIDS).[17] By the end of 1984, 7,699 cases of AIDS and 3,665 deaths had been recorded in America, with an additional cases 762 in Europe. By the end following year, over 20,000 cases were recorded globally, reaching every inhabited region in the world.[12]
Early stages of the epidemic in China
The first recorded death in China due to AIDS was a male Argentine-American[18] tourist and California resident who died in Beijing on 6 June 1985.[19] The Chinese government focused initially on preventing foreigners from transmitting the disease to its citizens, viewing it primarily as a consequence of a Western lifestyle.[20]
By 1998, HIV/AIDS was present in all 31 provinces and administrative regions of China, and government statistics indicated 60–70% of those infected were drug users.[21] Other major modes of transmission included infected blood spread through blood donation clinics across the country and the sex trade. Before either of these routes of infection were identified, however, a handful of people contracted HIV after receiving transfusions of contaminated hemophilia blood products from the United States.[22]
Contaminated blood imports
Through the early 1980s, multiple American pharmaceutical firms exported medical blood products contaminated with HIV to East Asia. Bayer Corporation exported plasma knowing the risks of HIV transmission, resulting in over one hundred infections in Taiwan and Hong Kong.[22] Factorate, a Factor VIII product of Armour Pharmaceuticals Company,[18] was imported to China and used in blood transfusions in 19 people in Zhejiang province between 1983 and 1985. Four of the recipients, all hemophiliacs, were infected with HIV, making them at the time the first identified cases of native Chinese infected within the country's borders.[23] Armour had been aware that original sterilization methods for Factorate were inadequate since at least 1985.[24]
The Chinese government reacted to the threat of HIV in the blood supply before any confirmed cases of infection had occurred. In September 1984, the Chinese Ministry of Health, in conjunction with the Ministry of Foreign Economic Relations and Trade (now the Ministry of Commerce) and the General Administration of Customs, issued a notice restricting imports on foreign blood products, including a complete ban on blood coagulation factors, specifically to prevent HIV/AIDS from entering the country. The bans were poorly enforced by some local governments, prompting central authorities in August 1985 to issue another notice nationwide, reiterating the ban and ordering all sub-national governments to comply.[25] On 30 January 1986, all blood products, with the sole exception of human serum albumin, were banned from import into China for both organizational and personal use.[26]
In 1989, central authorities became aware of a large outbreak of HIV/AIDS in western Yunnan province, in the border city of Ruili. 146 cases had been identified, mostly in injection drug users (IDUs), and Yunnan soon became the most heavily impacted province in China.[1][27] The outbreak was the first instance of a widespread, native infection in China, and stunned officials previously concerned mainly with preventing infection through sexual contact with foreigners.[20]
Yunnan borders the Golden Triangle region of Southeast Asia and has been a major hub for drug trafficking.[28][29] HIV likely crossed into China along heroin trafficking routes from Myanmar.[30] As heroin grew in popularity in Chinese border regions, injections with used needles became more common, greatly accelerating the rate of infection.[31] The disease spread over the next several years, confined mainly to drug using populations of ethnic minorities[32] in poorer, rural areas, reaching other high-risk groups and provinces by 1995.[1][33]
Sichuan and Xinjiang first reported HIV outbreaks among injection drug users in 1995, the first two provinces besides Yunnan to do so. The following year, cases were confirmed in Guangdong, Guangxi, Beijing, Shanghai, and Guizhou.[34] Additionally, an independent outbreak of a separate sub-strain of HIV among IDUs began in 1997 in the city of Pingxiang, Guangxi. Drug users crossed the border into northern Vietnam, where heroin was similarly smuggled in from Myanmar, and shared needles with Vietnamese dealers and users to test purchases before returning to China.[35]
Unique to China was the large-scale transmission of HIV through blood donation centers in the early to mid-1990s. The ban on blood product imports from the preceding decade restricted China's blood supply, making blood donation more lucrative,[36] particularly for inadequately funded rural healthcare systems already weakened by privatization.[37][38] Additionally, medicines containing blood plasma became popular among Chinese consumers, also contributing to demand for blood.[39] By 1990, thousands of public and commercial blood and blood plasma collection centers had been established across China, attracting donors with payments that could equal over a month's worth of income for some farmers.[40] A significant grey market of poorly regulated "bloodheads" (simplified Chinese: 血头; traditional Chinese: 血頭, xuètóu, coll. xiětóu) concurrently arose.[37]
The unsanitary practices in the blood market led to massive propagation of the HIV virus among rural populations. Donation centers frequently recycled needles, mixed blood donations without screening, and failed to adequately sterilize equipment, spreading blood-borne disease to both donors and recipients.[29] For plasma donations, blood was often mixed with other donors' samples and reinjected after plasma extraction.[39][41] Wu, Rou, and Detels (2001) found that 12.5% of plasma donors in eastern China tested positive for HIV, compared to 1.3% of non-donors; infected donors spread the disease to marital and other sexual partners.[42]
In 2004, official estimates put the number of people infected via unsafe blood donation practices across the most heavily impacted provinces — Henan, Hebei, Anhui, Shaanxi, and Shanxi — between 200,000 and 300,000. Gansu and Qinghai also reported infections stemming from the commercial blood trade during the same time period. Overall, 24% of all HIV/AIDS cases in China in 2004 had been attributed to blood donation and related activities.[43]
The phenomenon was especially prevalent in Henan, where it was promoted by local officials, including Henan Ministry of Health director Liu Quanxi[36] and provincial Communist Party SecretaryLi Changchun,[44] to promote economic growth. An internal report compiled in August 2002 by the Henan Ministry of Health, leaked by prominent AIDS activist Wan Yanhai, estimated that 35–45% of blood donors in some areas of the province had been infected due to poor safety precautions in clinics.[39]
The Chinese government was slow to admit and respond to the problem after it was identified, and initially repressed efforts to expose it. Shuping Wang and Gao Yaojie, two female doctors from Henan, mounted campaigns to expose the dangerous practices they saw in the early 1990s that put donors at risk for HIV infection.[44] The central government eventually ordered commercial clinics to be shut down in 1995, reopening them in 1997 after stronger regulations on blood donation practices were instituted,[45] although there is evidence that dangerous and unhygienic practices were not completely eliminated.[46]
Both Gao and Wang eventually left China for the United States, citing apparent government harassment and intimidation resulting from their advocacy efforts.[47] Even after acknowledging the issue, central and local government bodies sought to suppress discussion or coverage. Wan Yanhai was arrested in 2003 for attempting to screen a movie about the scandal in Beijing.[36] In 2004, while acknowledging some victims had contracted HIV because of inadequate hygiene in blood donation centers and agreeing to provide compensation, authorities still sought to classify such infections as resultant of use of drugs or prostitution in official records.[47]
Sex trade
While the majority of early infections occurred as a result of intravenous injection transmission or tainted blood supplies, prostitution also played a role spreading HIV/AIDS. China's economy rapidly grew as a result of Reform and Opening Up policies, and patronage of commercial sex workers, many of whom were injecting drug users, grew among both wealthy businessman and migrant worker populations, bringing HIV back to their hometowns and other cities.[29] Overall, however, the commercial sex industry was not as major a vehicle of transmission as drug injection and blood donation were, and HIV infection rates among female sex workers remained relatively low throughout the 2010s.[48]
25,266 HIV infections were recorded in 2005, with the most (4750) in Yunnan, and only one recorded in Tibet. (Hong Kong and Macau not included.)[51]
81,696 HIV infections were recorded in 2015, with the most (13,457) in Sichuan and the least (148) in Tibet.[51]
Data collection and reliability
Data on HIV/AIDS up through the early 2000s was very imprecise. Passive disease surveillance methods were established in 1986, with local clinics and medical providers reporting confirmed cases progressively through district, city, and provincial channels, and then ultimately to three separate national agencies under the Ministry of Health.[52][53] The Chinese government did not begin active surveillance and systematic data collection until 1995, when 42 national surveillance sites were established in 23 provincial-level regions with the help of the World Health Organization.[54] By 2006, China had achieved comprehensive HIV/AIDS surveillance nationwide, following expansion of the surveillance network to over 300 sites and reforms of the national reporting systems, although rural areas remained under-covered.[55] By 2010, 1888 surveillance sites had been established.[56]
Data from before the development of comprehensive surveillance suffered a number of shortcomings, including minimal coverage of the general population due to focus on high-risk groups, poor data on men who have sex with men (MSM), stovepiping among different government entities, and difficulties obtaining data from private healthcare providers.[57] Through the early 2000s, the Chinese government limited discussion of data and statistics of HIV/AIDS in the country, and media only reported numbers approved by the government.[58][59]
Accordingly, estimates from the period of the epidemic often were imprecise, tending to overestimate the overall number of cases. China did not begin to produce regular, systematic estimates of the prevalence of HIV/AIDS until 2003, doing so in conjunction with the United Nations, World Health Organization, and United States Centers for Disease Control.[60] This initial estimate was tentatively 840,000 cases nationwide, but with a potential range of 430,000 to 1.5 million.[61] This was revised down to 650,000 in 2005.[62]
Other international estimates tended to greatly overstate the presence and potential growth of HIV in China before more reliable official data was available.[63] For example, in 2002, a report by the United Nations Theme Group on HIV/AIDS in China, entitled "HIV/AIDS: China's Titanic Peril", had estimated up to 1.5 million infected cases, and warned of "[a] potential HIV/AIDS disaster of unimaginable proportion".[64] A 2002 report by the US National Intelligence Council projected 10–15 million cases in China by 2010.[65]
Overall, the availability, precision, and coverage of HIV/AIDS data in China improved significantly from 2003 onward.[66] Beginning in 2010, the Chinese government again expanded the scope and number of HIV surveillance sites, increasing coverage of all groups and expanding to cover larger portions of the population and providing more comprehensive information on the disease.[67] Data gathered through the current system has generally been reliable,[68] although issues with standardized protocols across different sites and coordination among different levels of government were identified in independent studies.[67]
Current transmission
The prevalence of HIV/AIDS in China per 100k people, for the year 2016
HIV in China is primarily transmitted through sexual contact, which accounts for over 90% of new infections.[69][70] Sexual transmission gradually began to overtake the originally predominant routes of transmission, injection drug use and unsafe blood donation practices, throughout the 1990s and into the mid-2000s.[8][71] In 2005, sexual transmission accounted for 50% of all new infections,[7][72] and by 2007, a majority of HIV/AIDS cases overall were related to sexual transmission pathways.[73]
Currently, major high-risk groups for HIV infection include intravenous drug users, men who have sex with men (MSM), and sex workers.[74][75] The Chinese government has additionally established data collection and monitoring sites targeting male migrant workers, long-distance truck drivers, male STI clinic patients, antenatal care clinic patients, and college students.[76]
MSM in particular have seen a significant increase in transmission rates since epidemiological studies examining them as a group began in 2000.[77][78] MSM represented 26% of new reported cases in 2014, up from 2.5% in 2006.[79] Increased migration from poorer regions with high HIV prevalence to urban areas and somewhat liberalized attitude towards homosexuality in China over the last two decades, resulting in more overall sexual activity, have been hypothesized as factors driving this trend.[80]
MSM are also generally at a higher risk for contracting STIs, including syphilis, which may form a coinfection with HIV.[81][82] Drug use contributes little to HIV infection among MSM, with the overwhelming majority of new cases being the result of sexual activity. More than one-fifth of MSM are married to women, which might speed the transmission of HIV to the general population, and outreach to this subgroup in particular can be difficult.[83]
Mortality rates
The standardized mortality rate of HIV/AIDS rose from 0.33 per 100,000 people in 1990 to 2.50 per 100,000 in 2016, and the rate is higher in men than in women. Overall rates of mortality continue to grow as more individuals are infected.[84] The provision of antiretroviral therapy (ART) among infected individuals, however, has greatly decreased mortality among patients receiving care since the early 2000s; by 2014 86.9% of eligible patients were receiving some form of ART. [85]
Control and prevention
Overview of policy response
The response of the government of China to the HIV/AIDS crisis evolved in tandem with the epidemic itself. Generally, policy moved from preventive and containment measures aimed at keeping the disease from reaching the general population, often with a reliance on enforcement of public morality, to more active, data-driven control measures involving targeted education and harm reduction programs.[86] Early law and policy implementation were often hindered by lack of knowledge among lawmakers on the severity and impact of HIV/AIDS and its potential for growth within China.[87]
1985–1988: protection from foreign infection
The first phase of Chinese HIV/AIDS policy ran from the first recorded in-country death in 1985, of a tourist in Beijing, until 1988/89, when the identified epidemic pattern expanded following the discovery of the outbreak in Yunnan. From 1985 to 1988, only 22 individuals tested positive for HIV in China, 18 of whom were foreigners or Overseas Chinese.[88] HIV/AIDS was commonly viewed as a consequence of a Western lifestyle, and thus government efforts concentrated on protecting China from foreign transmission and promoting moral behavior and traditional values among citizens.[89] "AIDS" was often punned in Chinese as "loving capitalism disease" (simplified Chinese: 爱资病; traditional Chinese: 愛資病; pinyin: Àizībìng), and public health authorities held that because homosexuality and other "abnormal" sexual behaviors were not prevalent in Chinese society, the disease had limited potential to spread.[21][90][91]
In December 1985, the Ministry of Health submitted a report to the Secretariat of the Chinese Communist Party and the State Council, outlining the spread of the disease from Africa to Europe and America, emphasizing the predominantly sexual transmission routes, and listing measures the Ministry had taken to prevent its further spread into China.[92] Laws and regulations attempting to eliminate the risk of foreigners infecting native Chinese were promulgated, under the assumption that this could keep the disease out of the country altogether.[93]
By 1986, foreigners intending to stay over a year were required to undergo HIV testing, and HIV-positive people were legally barred from entering China.[94][95]TheNew York Times reported that police in some cities were instructed to prevent foreigners from coming into sexual contact with Chinese people, including in discothèques, dance halls, and brothels.[96] These early policies of containment, which also included wider crackdowns on drug use and sex work, did little to check the spread of the disease, and possibly hindered initial identification of its domestic reservoirs.[97]
1989–1994: control of limited epidemic
The discovery of the outbreak in Yunnan triggered a large increase in the number of reported cases as the disease rapidly spread among high-risk groups. The Yunnan outbreak forced health officials to reconsider aspects of Chinese HIV/AIDS policy,[98] although efforts were still largely focused on policing drug use and prostitution.[99]
Social science research on previously taboo topics, including homosexuality, sex work, and drugs, began to proliferate during this period and served to inform policy that did not rely on a view of HIV/AIDS as an inherently Western problem.[100] The Ministry of Health began exploring methods such as the implementation of behavioral interventions and free STI testing among high risk populations.[101] Officials also experimented with less punitive counter-drug policy, such as the establishment of a limited number of methadone clinics in larger, well-equipped medical institutions in 1993.[102] A wide range of officials—including State Council officials and health, security, justice, and education civil servants—were sent on tours to study policy and disease control strategies in places heavily affected by AIDS, such as the United States, Brazil, Australia, and Thailand.[103]
1995–2003: combatting widespread epidemic
In 1995, HIV cases began appearing consistently beyond the borders of Yunnan as the epidemic entered a phase of rapid growth.[104][33] The government grew more concerned with the public health threat HIV/AIDS posed. Previously uncommon harm reduction strategies began to appear in limited capacities, a departure from previous years.
Several novel state organizations were established at the national level to strengthen the government response to HIV/AIDS. The compartmentalized nature of the Chinese bureaucracy historically made work on HIV/AIDS difficult because different agencies and departments were responsible for different aspects of data collection, service provision, and healthcare.[105] In 1996, the State Council established STD/AIDS Prevention and Control Coordinating Meeting System (国务院防治艾滋病性病协调会议制度) to coordinate policy at the national level, although this body met infrequently.[106] On 1 July 1998, following nearly two years of planning, the National Center for HIV/AIDS Prevention and Control under the Ministry of Health (卫生部艾滋病预防控制中心) was established. This entity became the National Center for AIDS/STD Control and Prevention of the Chinese Center for Disease Control and Prevention (NCAIDS/STD, 中国疾病控制中心性病艾滋病预防控制中心) in January 2002.[107]
A number of substantive policy developments related to HIV/AIDS occurred during this period. In September 1995, the State Council and Ministry of Health release "Recommendations on Strengthening AIDS Prevention and Control" (关于加强和控制艾滋病工作的意见), developing and reviewing laws and regulations related to HIV/AIDS control and improving enforcement mechanisms. HIV/AIDS work was included in the overall national development strategy of China, and the government signaled openness to the support of non-governmental organizations in combatting the epidemic.[108][109]
Blood donation centers, closed nationwide in 1995 in response to the Plasma Economy scandal, were reopened in 1997–98 with the passage of the Blood Donation Law (中华人民共和国献血法).[110][111] In 1998, needle exchange programs were implemented in Guangxi, and further expanded in the early 2000s as their efficacy became clear, although some localities and national government departments (such as the Ministry of Public Security) remained opposed to such efforts on the grounds that they encouraged drug use.[112]
In November 1998, the State Council released a document entitled "China’s National Medium-and Long-Term Strategic Plan for HIV/AIDS Prevention and Control (1998–2010)" (关于印发中国预防与控制艾滋病中长期规划(1998–2010年)), outlining the Chinese government's goals to be carried out at local, provincial, and national levels, and further monitored through regular assessments. The document included a number of specific objectives and mandates, including:
Ordering local governments to consider HIV/AIDS prevention and treatment as a part of all policy planning and socioeconomic development goals;
Disseminating knowledge about the disease and its prevention (including promotion of condom use) to the general population through publicity campaigns, the school systems, and mass media (a 2001 survey found that 20% of the general population had not even heard of the disease[113]);
Strengthening surveillance and data collection and coordinate standardized testing, training, and screening measures nationally;
Increasing research both on HIV/AIDS treatments and on epidemiological studies of the disease; and
Developing and improving HIV/AIDS-related legislation and regulations nationwide.[114]
The State Council further consolidated and expanded work on HIV and AIDS with China's first five-year plan for AIDS/HIV, covering 2001–2005. While still cautious about embracing harm reduction policies for fear of promoting social ills, the plan was a milestone for such policies overall and laid the groundwork for more ambitious efforts in following five-year plans.[101][7]
2003–present: evidence-based approaches post-SARS
The 2002–2004 SARS outbreak, which originated in Foshan, China, led to significant changes to public health policy, including shifts in the state's approach to HIV and AIDS. Funding and political support for HIV/AIDS-related policies began to increase markedly.[115][116] Wu et al. (2007) argue that "SARS showed not only how infectious diseases could threaten economic and social stability but also the effect of China’s policies on international health problems”, resulting in increased expertise and attention devoted to HIV/AIDS overall.[117]
The new administration of Hu Jintao and Wen Jiabao, which ascended to power in March 2003, heightened commitment to evidence-based policy to fight HIV/AIDS. Wu Yi was appointed the Minister of Health, and her tenure saw a greater willingness to publicly discuss health crises like HIV/AIDS; Wu even met with activist Gao Yaojie shortly after her appointment.[37][47][118]
In September 2003, Vice Minister of Health Gao Qiang outlined five promises of the Chinese government in its fight against AIDS in an address to the United Nations General Assembly's special session on HIV/AIDS. Gao said the Chinese government would commit to free antiretroviral therapy for poor rural and urban citizens, free counseling and treatment services, free treatment for pregnant women and testing for their children, free tuition and fees for children affected by HIV/AIDS, and financial support for any affected families. On World AIDS Day, 1 December 2003, while meeting with an AIDS patient in an effort to decrease stigma surrounding the disease,[21]Premier Wen also formally announced the "Four Frees and One Care" (四免一怀) policy based on the measures outlined by Gao.[116] Funding initially came from a $90 million grant of The Global Fund to Fight AIDS, Tuberculosis and Malaria, focusing on free testing for those in provinces where blood donation had been a major channel of infection.[119]
In March 2006, the State Council implemented the "Regulation on the Prevention and Treatment of HIV/AIDS", codifying principles of prevention, treatment, and behavioral interventions into a national framework.[120] It explicitly endorsed methadone treatment and condom education, among other measures, spurring the establishment of over 600 clinics nationwide by 2010.[121] The law also formally proscribed discrimination of people based on their HIV status, and no longer prevented HIV-positive people from entering the country.[citation needed]
International cooperation and funding
Prior to 2003, the majority of the capital for anti-HIV/AIDS policies and programs in China came from foreign sources, including NGOs like the Red Cross and Bill and Melinda Gates Foundation, foreign government agencies like the US Centers for Disease Control and Prevention, and international multilateral organizations like the UN and WHO.[122] Dedicated funds for HIV/AIDS were first allocated by the Ministry of Finance in 1998.[123] By 2015, 99% of HIV/AIDS response efforts were funded by domestic sources, and total expenditures reached nearly RMB 7 billion (approx. USD 1 billion) for the fiscal year 2017.[124]
Discrimination against people with HIV/AIDS
Discrimination against HIV-positive individuals is an ongoing issue in China. Various provinces have historically adopted different measures related to people with HIV, most of which restrict their equal access to the public sphere. In some provinces in municipalities in the early 2000s, people with HIV were prohibited from holding certain jobs, HIV mothers could be required to undergo an abortion, and an HIV-positive couple could be legally barred from marriage on medical grounds.[125]
The 2006 Regulation on the Prevention and Treatment of HIV/AIDS formally barred legal discrimination against anyone based on the HIV status. While lauding the Regulation as a major step forward, the United Nations Economic and Social Commission for Asia and the Pacific in 2015 reported that local governments often functionally ignored its provisions.[126] A 2016 study in Guangzhou found that large numbers of healthcare providers also discriminated against HIV-positive patients, with over one-third refusing to treat such patients altogether.[127]
In January 2013, China saw its first lawsuit awarding damages to a plaintiff on the grounds of HIV/AIDS discrimination. The plaintiff had been rejected for a job as a school teacher by the education bureau of Jinxian County, Jiangxi province specifically due to his HIV status.[128]
Extracts of traditional medicines have served as bases for trials of antiviral therapies, including baicalin[130] and Dantonic.[131] A group of nine HIV/AIDS patients in 2017 were reported to have been functionally cured through TCM treatments,[132] but these trials lacked controlled, regular observations.[133] A 2018 study suggested substantive differences in protein expression and signaling in certain TCM-identified syndromes for those with HIV/AIDS.[134] Controlled studies have yet to demonstrate any effect on long-term survival among HIV/AIDS patients, however, its validity is difficult to discern, and research is lacking on the interactions between Western and Traditional Chinese pharmacological products.[135][136]
In China, like elsewhere, HIV/AIDS activists have played an important role in promoting public awareness and education about the disease, helping to prevent discrimination against people living with HIV/AIDS and highlighting factors which may impede efforts to check the spread of the disease. Compared to other social movements, the Chinese government has historically been more tolerant of HIV/AIDS-focused NGOs and civil society organizations, relying on them to reach out to marginalized groups most vulnerable to the disease.
The government at all administrative levels has also often sought to suppress or minimize activism perceived as sensitive, obscene, or a threat to stability, including that related to HIV/AIDS.[137] This phenomenon was particularly pronounced in Henan, where the initial blood donation outbreak, in which local authorities were extensively involved, was most severe.[138][139]
The process of the effect of HIV/AIDS can be described as having three key stages: first, the effect experienced at the micro level; second, at the sectoral level; and finally, at the macro level. The effect began to be observed in China at the micro, or household level, and will most certainly be observed in the future at the sectoral level. Individuals and families have been bearing both the economic and social costs of the disease, and the poverty of those affected have increased and will further increase substantially.[141]
Expenditures for the health sector will increase, for both treatment and prevention interventions. The macro level has been mostly unaffected. But if without effective preventive action, the HIV spread in the general population at large will affect the macro level as have happened in some countries in sub-Saharan Africa.[142]
An abridged version of Robert Bilheimer's acclaimed US-made 2003 documentary A Closer Walk was shown on China Central Television (CCTV) on World AIDS Day, 1 December (Friday), 2006, and was rerun Sunday and Monday. It was viewed by around 400 million people. The 75-minute-long documentary, narrated by actors Will Smith and Glenn Close, had premiered in the United States in 2003.[citation needed]
^ abZhang et al. 2006, p. 2075: "However, our finding of a large number of sexually transmitted CRF01_AE viruses in Yunnan among non-IDUs is new. In particular, the rapid increase of HIV-1 prevalence among non-IDU populations has emerged as an alarming trend. IDU dominance in the late 1980s and throughout the 1990s has now been gradually replaced by those infected through heterosexual contact or other routes.”
^He & Detels 2005, p. 827: "At some local government-run blood banks and in many private underground blood banks operated in the early and middle 1990s in central China, blood was often collected from several villagers at the same time, and mixed together in a container or a centrifuge from which the plasma was collected. ... Such procedures, as well as recycling of used needles and inadequately sterilized equipment, allowed HIV to be rapidly transmitted among these donors, generating a large number of HIV-infected farmers and peasants.”
^Ministry of Health of the PRC and General Administration of Customs of the PRC (26 August 1985). 关于禁止ＶＩＩＩ因子制剂等血液制品进口的通知Archived 2020-02-22 at the Wayback Machine" ["Notice Regarding the Prohibition on Importing Factor VIII and Other Blood Products"] (in Chinese). "防止获得性免疫缺陷 （简称AIDS）我国，卫生部已于1984年9月会同经贸部、海关总署以（84）卫药字第22号联合通知，限制进口国外血液制品。通知发出后，有的省、市卫生厅（局）认真执行，严格把关，控制血液制品的进口。但有的省、市卫生厅（局）尚未引起重视，对进口血液制品既不控制，又不认真审查把关，仍在大量进口血液制品，且进口制品经检验不合格的情况也日趋严重。" ["In order to guard against the entry of acquired immunodeficiency syndrome (AIDS) into the country, the Ministry of Health, with the General Administration of Customs and the Ministry of Trade and Foreign Economic Cooperation, disseminated the joint Health Notice (84) No. 22 limiting the import of foreign blood products. Following the notice, some provincial and municipal health bureaux implemented it diligently with strict checks. Some provincial and municipal health bureaux, however, have not attached importance to the notice, not only failing to control the import of foreign blood products, but also not being serious in their examinations and checks. They are still importing large volumes of foreign blood products, and moreover, these products have increasingly come to fail inspections."]
^Ministry of Health of the PRC (30 January 1986). "关于禁止进口ＶＩＩＩ因子制剂等血液制品的通告"Archived 2020-02-22 at the Wayback Machine ["Announcement Regarding the Prohibition on Importing Factor VIII and Other Blood Products"] (in Chinese).
^Feng, Xiaohua. "抗艾渐入核心？药物控制病毒使感染者成为非传染源" [Towards the Core of Fighting AIDS? Medicine Controls Virus, Making Infected Non-Infectious]. Chinese Center for Disease Control and Prevention (in Chinese). Yicai News. Retrieved 18 February 2020.
^"2018年全国法定传染病疫情概况 [2018 National Legally Designated Infectious Disease Epidemic Summary]" (in Chinese). National Health Commission of the People's Republic of China. Archived from the original on 31 January 2020. Retrieved 1 March 2020. The top five disease by mortality figures for this report in descending order are: AIDS, tuberculosis, viral hepatitis, rabies, and Japanese encephalitis. (报告死亡数居前5位的病种依次为艾滋病、肺结核、病毒性肝炎、狂犬病和乙型脑炎，占乙类传染病报告死亡总数的99.27%。)
^ ab"艾滋病数据库". 公共卫生科学数据中心. 中国疾控预防控制中心公共卫生监测与信息服务中心. Archived from the original on 2019-05-08. Retrieved 2019-05-08.
^Jia et al. 2007, p. 1042: "HIV/AIDS was reportable through three theoretically complementary but practically overlapping components: (1) The HIV/AIDS Reporting System, coordinated by the Division of Epidemiology, National Center for AIDS/STD Prevention and Control (NCAIDS) of the Chinese Academy of Preventive Medicine (CAPM), (2) The Communicable Diseases Reporting System, coordinated by the Division of Epidemiology, Institute of Infectious Disease Control and Prevention, CAPM (includes 35 notifiable infectious diseases), and (3) The National STD Surveillance System, coordinated by the Nanjing STD Center of the Chinese Academy of Medicine (data on eight STDs including HIV); China CDC and US CDC, 2002; China CDC, 2006). Through these three systems, HIV/AIDS case reports flowed from the health facilities or clinics as follows: (1) to the local district, county, or county-level city, (2) to the prefecture or prefecture-level city, (3) to the provincial health departments, and (4) to three separate national agencies."
^Hesketh 2007, p. 622: "[P]redictions of the size of the epidemic were substantially overestimated by several expert bodies. ... The National Intelligence Council claimed that [its] figures were more reliable than previous estimates because they did not rely on official sources, which the National Intelligence Council asserted 'systematically understate the actual figures', but rather incorporated assessments by academics and non-governmental organisations working in the field."
^Wang et al. 2010, pp. ii25–ii26: "Repeated rounds of national HIV/AIDS estimate exercises in 2003, 2005, 2007 and 2009 have generated data that more accurately reflect China’s heterogeneous epidemic. Improvements in data quality and data availability have improved the precision of HIV/AIDS estimates, providing information that is critical to public health priority setting and policymaking."
^Tian, Xiaohang (23 November 2018). "国家卫健委：我国艾滋病全人群感染率约万分之九" [NHC: China's National AIDS Infection Rate Approximately 9 per 10,000]. www.gov.cn (in Chinese). Xinhua News. Archived from the original on 6 May 2019. Retrieved 1 March 2020. 值得注意的是，当前，性传播是我国艾滋病主要传播途径。2017年报告感染者中异性传播占69.6%，男性同性传播占25.5% [It is worth mentioning that at present, sexual transmission is the primary transmission channel of AIDS in China. Of those infected in the 2017 report, 69.6% were from heterosexual transmission, and 25.5% male homosexual.]
^"艾滋病检测核心信息 [Core Information on AIDS Testing]" (in Chinese). Chinese Center for Disease Control and Prevention. Archived from the original on 1 March 2020. Retrieved 1 March 2020. 近年来，通过检测并诊断报告的感染者中，每100个就有90个以上是经性途径感染。[In recent years, of those tested, confirmed, and reported as infected, greater than 90 of every 100 were infected through sexual transmission.]
^Dong et al. 2019, p. 9: "Our study showed an increased tendency in the HIV prevalence among MSM as time progressed (P < 0.001) (Fig. 2). The increasing HIV prevalence may be associated with several factors: 1) the increasing migration for better employment opportunities and living conditions from regions with a high HIV prevalence, such as from southern China or from the countryside, to large cities, which have a relatively open culture and convenient sexual venues (e.g., bars, saunas, parks, and sex clubs.); 2) the gradual changes in attitudes towards sex and increased openness of male homosexuality in China with changes in Chinese society, although homosexuality is still not widely accepted by the general population; and 3) the common occurrence of marriage between MSM and women because MSM might act as a bridge for HIV transmission from other MSM to the general population."
^Wu, Rou & Cui 2004, p. 11: "Sporadic reports of HIV infection and AIDS cases did generate awareness of AIDS among some lawmakers, but their knowledge of the real implications of the HIV/AIDS epidemic was limited. Therefore, they did not know how to take appropriate action from a legal point of view. ... Lawmakers do not understand the complexity of AIDS issues, and people who have sound knowledge of AIDS have not had the opportunity to be involved in the lawmaking processes."
^Xu, Han & Zeng et al. 2013, §1.1: "这一时期，几乎所有人都认为艾滋病是同西方生活方式相联系的，是从境外进来的，因此，只要守住国门就能杜绝，于是，形成了所谓'御敌于国门之外'的策略。 ... 这一阶段防治特征主要表现为严把国境关：注重监测、严防传入；同时，强调道德宣传，严惩卖淫、嫖娼等行为。此时，对艾滋病综合干预的思想(T推广使用安全套)还未诞生，预防手段显示出明显的意识形态和依靠强硬的行政手段的特点。".
^FIDH 2005, p. 7: "AIDS was regarded as a disease linked with the ideology of capitalism… In 1987, the Minister of Health, Chen Minzhang, announced that AIDS would not spread in China as it was transmitted by homosexuality and promiscuity, evils which were unknown to China."
^Ministry of Health of the People's Republic of China (10 January 1985). "关于加强监测、严防艾滋病传入的报告" [Report on Strengthening Monitoring and Strictly Defending Against Transmission into [China] of AIDS] (in Chinese). Retrieved 7 March 2020.
^Wu et al. 2007, p. 680: "In much the same way as other countries, traditional public-health methods of containment and isolation of infectious disease cases proved ineffective. Containment policies occurred in the context of rapid social and economic change, in which there were increases in drug use and changing sexual mixing patterns. These early policies did little to stop transmission of HIV; in fact, they probably promoted concealment of risk activities and made identification of HIV reservoirs more difficult."
^Xu, Han & Zeng et al. 2013, §1.2.2: "1989年，在云南边境地区的吸毒人群中集中发现146例HIV感染者，引起人们的震惊，开始反思'严防传入'策略的局限性：在日趋开放的社会里，能否通过封闭的方式解决公共卫问题？经过争论与探讨，艾滋病防控策略开始向主动预防转变，对一些干预工作开展探索性的试点。" ["In 1989, the discovery of 146 HIV cases concentrated among drug users in the border region of Yunnan shocked many and forced reflection on the limits of the 'protection against [HIV] entering' strategy: as society grew more and more open, could closing [the country] off really solve such a public health problem? After much debate and investigation, AIDS control policy began to turn toward proactive prevention, and pilot schemes exploring the development of intervention work began."]
^Jia et al. 2007, p. 1045: "The surveillance data from 1995 to the present (2006) suggested that the HIV/AIDS epidemic began a Rapid Spread Phase in 1995 (Fig 2). The epidemic expanded rapidly among IDUs in rural border areas of Yunnan Province, where China borders Myanmar, Lao PDR, and Vietnam close to the 'Golden Triangle', soon spreading to IDUs in nearby cities."
^National Center for AIDS/STD Control and Prevention. "Chronology of NCAIDS". ncaids.chinacdc.cn. Archived from the original on 4 October 2018. Retrieved 7 March 2020.
^Xue 2005, p. 460: "The main principles of the circular include adopting the HIV/AIDS issue into national development strategy, accepting the non-government organization concept and support, enhancing information communication to all sectors of the population, reinforcing the management of blood safety, surveillance and quarantine, increasing funds, strengthening international cooperation, etc."
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