HIV/AIDS in China can be traced to an initial outbreak of the human immunodeficiency virus (HIV) first recognized in 1989 among injecting drug users along China's southern border. Figures from the Chinese Center for Disease Control and Prevention, World Health Organization, and UNAIDS estimate that there were 1.25 million people living with HIV/AIDS in China at the end of 2018, with 135,000 new infections from 2017. The reported incidence of HIV/AIDS in China is relatively low, but the Chinese government anticipates that the number of individuals infected annually will continue to increase.
While HIV is a type of sexually transmitted infection, 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. By 2005, 50% of new HIV cases were due to sexual transmission, with heterosexual sex gradually becoming the most common means of new infections in the 2000s. 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. 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.
History Global background
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 Kinshasa, likely having initially crossed from chimpanzees around 1920. 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.
The US Centers for Disease Control and Prevention (CDC) recognized unusual outbreaks of opportunistic infections among gay men in 1981, and the disease was initially referred to as gay-related immune deficiency (GRID), although it was quickly understood to also infect heterosexuals as well. In 1982, the CDC adopted the name "acquired immune deficiency syndrome" (AIDS). 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.
Early stages of the epidemic in China The first recorded death in China due to AIDS was a male Argentine-American tourist and California resident who died in Beijing on 6 June 1985. 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.
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. 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.
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. Factorate, a Factor VIII product of Armour Pharmaceuticals Company, 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. Armour had been aware that original sterilization methods for Factorate were inadequate since at least 1985.
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.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 " ["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."] 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.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" ["Announcement Regarding the Prohibition on Importing Factor VIII and Other Blood Products"] (in Chinese).
Southern intravenous drug users
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. 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.
Yunnan borders the Golden Triangle region of Southeast Asia and has been a major hub for drug trafficking. HIV likely crossed into China along heroin trafficking routes from Myanmar. As heroin grew in popularity in Chinese border regions, injections with used needles became more common, greatly accelerating the rate of infection. The disease spread over the next several years, confined mainly to drug using populations of ethnic minorities in poorer, rural areas, reaching other high-risk groups and provinces by 1995.
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. 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.
Bloodhead controversy
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, particularly for inadequately funded rural healthcare systems already weakened by privatization. Additionally, medicines containing blood plasma became popular among Chinese consumers, also contributing to demand for blood. 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. A significant grey market of poorly regulated "bloodheads" (, xuètóu, coll. xiětóu) concurrently arose.
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. For plasma donations, blood was often mixed with other donors' samples and reinjected after plasma extraction. 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.
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.
The phenomenon was especially prevalent in Henan, where it was promoted by local officials, including Henan Ministry of Health director Liu Quanxi and provincial Communist Party Secretary Li Changchun, 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.
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. 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, although there is evidence that dangerous and unhygienic practices were not eliminated.
Both Gao and Wang eventually left China for the United States, citing apparent government harassment and intimidation resulting from their advocacy efforts. 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. 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.
Sex trade