It's hard to fight an epidemic when no one wants to talk about the cause. In China, a country whose last decade has been defined by economic growth and social opening, silence still enshrouds many aspects of the nations' sex life, and not, health experts say, without consequences. While most industrialized nations have seen HIV/AIDS death rates steadily decline in the past 10 years, China announced in February that the HIV virus took the lead as the deadliest infectious disease in the nation in 2008, killing nearly 7,000 people in the first nine months of the year. "It's very difficult to talk about sex in schools. It's very difficult to talk about sex in relationships. It's very difficult to talk about sex in the workplace," says Bernhard Schwartländer, coordinator of UNAIDS in China. "If they don't know about it, how can they protect themselves?"
The fact that HIV, now regarded in the medical community as a preventable and treatable virus, is a significant and increasing cause of death in China shows that government programs are not reaching enough people, says Schwartländer. In the same government report, released in February, China's Ministry of Health also listed 264,302 diagnosed HIV cases across the nation nearly double the number in 2005. A lot of that increase is likely due to increased reporting and testing, but UNAIDS still cautions that the statistics reflect only a fraction of disease's real impact. At the end of 2007, the organization says some 700,000 people were still living with HIV in China. Of those, roughly 85,000 are believed to have developed AIDS. (See the top 10 medical breakthroughs of 2009.)
While that number isn't staggering UNAIDS estimates that 33 million people are living with HIV worldwide the potential for things to get worse is alarming. As the world's most populous nation, the upswing in the epidemic is of great concern, Schwartländer says. While HIV/AIDS became a visible public health issue in much of the developed world more than 20 years ago, China did not put real resouces into fighting the disease until 2003. Confronted by the UN's so-called 2002 "Titanic" report, which said China faced an AIDS epidemic of "proportions beyond belief" and compared the nation's leaders to officers onboard the doomed Titanic who refused to believe the ship was sinking until it was too late, Beijing launched the first national care program the following year to provide free services to those infected with the virus. "For a long time China missed the opportunity to tackle AIDS head on," says Schwartländer. "They tried to avoid it, and I think they really ignored the problem."
As a result, the stigma AIDS carries today in China remains strong and potentially dangerous. In a 2008 survey by the China AIDS Media Partnership, of the more than 6000 people surveyed, nearly 48% said they wouldn't knowingly eat with an HIV positive person. Thirty percent said HIV positive children should not be allowed to study at the same schools as uninfected children, and 40% said they would not willingly share workspace with a colleague they knew was HIV positive. The government has taken steps to improve these attitudes, including implementing an anti-discrimination law in March 2006, but perceptions like these don't help in the fight to educate people about their own risk of infection. "It's not something that can change overnight," says Schwartlander. "People have to get their mind around it."
In the meantime, other social stigmas may also be playing a part in the increasing cases. Together with the government, UNAIDS estimates there are anywhere from 30 to 50 million people vulnerable to HIV in China today, with sex workers, men who have sex with men and intravenous drug users all communities thought to have higher rates of infection than the general population facing the highest risk. After the new government numbers were released in February, Zhang Beichuan, a researcher at Qingdao University, told the state-run media that the high number of gay men entering into heterosexual marriages is a contributing factor to the increasing spread of HIV. Extra-martial, high-risk sex puts both those men and their wives at risk, according to a study Zhang conducted in 2006, and the enduring discrimination homosexuals face in China prevents many men from getting tested for HIV/AIDS or seeking treatment. Only with more understanding and tolerance will efforts to curb the spread of HIV be effective, Zhang said. (Read about Hong Kong's gay pride revolution.)
Health experts say China needs to ramp up its efforts to target these groups and others more effectively. In February, the World Health Organization warned Beijing of a steep rise in HIV among gay men unless prevention programs targeting them were greatly improved. Zunyou Wu, director of the National Center for AIDS/STD Control and Prevention at the Chinese Center for Disease Control and Prevention, says new programs are being developed, but that the government still relies heavily on members of the gay community to educate themselves. Sex workers also lack access to programs and materials they need to keep themselves safe. According to a November 2008 Beijing municipal report, of the 90,000 female sex workers in the capital, only 46.5 percent reported using condoms. With payments in some areas of the country as low as $5 per customer, many sex workers can't afford effective protection, and free condoms distributed in government programs are often low quality. "We hear the girls complain all the time that the condoms break when they use them," says Elaine Lam, of the Hong Kong-based sex workers support organization, Zi Teng, which works with sex workers in southern China.
Today, UNAIDS estimates that AIDS awareness programs are currently only reaching between 20 and 40 percent of China's at-risk communities. "China is a whole continent. It's 1.3 billion people," Schwartländer says. "The big question is always, 'How do we make sure these good, sensible policies and ideas are really implemented throughout the whole country?'" It is not enough to have good policies in Beijing; the work has to happen in the provinces and the communities where 60% of the nation actually lives. "Unless you understand how you can translate the policies into the realities of where the people are living, you will not succeed," he says. "There's an opportunity here to make sure 50 million people don't become infected."