It was early December, the day after World AIDS Day, 2010. I was back in Beijing for the first time in 23 years, standing outside the entrance to the Great Hall of the People on Tiananmen Square. I had an official invitation in hand to a high-level consultation on China’s national response to the AIDS epidemic, which is increasingly affecting women and girls.
My mind toggled back to my last visit to China in 1987, when the government had just decreed mandatory AIDS testing for foreign residents. At that point in the epidemic, Chinese public health authorities said the source of the HIV threat was outside of China and they relied on China’s strong heteronormative culture to protect its citizens from sexual transmission of AIDS. The government figured they could contain the threat by focusing on foreigners and a very small number of gay Chinese men – a highly stigmatized group in China, as elsewhere. Back then, AIDS was viewed predominantly as a “gay man’s disease.”
Fast forward to December 2010. Reports released by the Chinese government and UNAIDS on World AIDS Day indicated that HIV and AIDS in China have evolved much like other epidemics in Asia, transforming from one concentrated among groups most at risk for HIV, such as injection drug users, to a broader epidemic among the general population. Sexual transmission is now the primary mode of HIV infection in China: As of 2009, heterosexual transmission accounted for 42 percent of new cases and homosexual transmission for 32 percent. And emerging data show that patterns of risk are becoming increasingly complex, in part due to the rapidly escalating diffusion of HIV among men who have sex with men as well as with women. At the Great Hall event, government officials acknowledged the need to understand and address the complexity of China’s national epidemic.
So where does China go from here? As Chinese public health experts develop their national AIDS strategy, they may want to pay close attention to two related elements: the evolving nature of women’s vulnerability to HIV and the impact of stigma and discrimination in complicating an already complex situation.
Focusing on women is essential. Recent data indicate that a growing proportion of Chinese women are being infected with HIV through sexual transmission, from 30 percent in 2000 to 74 percent in 2009. HIV transmission within marriage now poses a credible threat to many Chinese women, particularly those wedded to men most at risk for HIV, such as migrant workers, men who have sex with men and injection drug users. Public health authorities’ efforts will go farther if they understand the role of power relationships between women and men, and how that can contribute to women’s vulnerability to HIV. They may also want to consider that social dynamics and sexual practices are fluid from setting to setting, and interact differently under different environmental conditions. This creates a multitude of “local” epidemics within China’s national epidemic – each requiring a well-tailored response.
This, I believe, includes working with civil society to reduce stigmatization of men who have sex with men and increase services available to them. As I talked with people leading AIDS programming for corporations, multi-laterals and foundations, it became apparent that very little is known about this community of men in China. Service providers are perplexed about how to reach this population and their sexual partners, both male and female, with information and services. We’ve studied HIV-related stigma extensively at ICRW, and our research in Cambodia and across the world may be useful in designing effective programs.
It’s critical that China’s next national AIDS plan, which is currently under development, lays the groundwork for an AIDS-free society. And I’m confident that the country has the ability to do so through policy, research and programs that tackle the underlying causes of women’s and men’s vulnerability to HIV.
Sarah Degnan Kambou is president of ICRW.