【桑葛石原研翻译系列】中国艾滋病及艾滋病干预现状分析

关键点

• 中国每年新增病例占全球新艾滋病毒感染病例的3%。据报告，仅2018年新增感染病例为14%，第二季度增加了4万例。

• 绝大多数是在一般人群中通过性传播的。2017年，中国稳步推进针对女性性工作者和男性恋者的全面干预计划。

• 缺乏全面的性教育是有效实施的主要障碍，公开讨论性健康和性健康仍然是禁忌。

• 虽然在解决艾滋病毒流行方面已经取得了重大进展，但艾滋病毒活动人士、非政府组织和民间社会仍在保持沉默。

中国对防治艾滋病采用多部门联合协作的方法，涉及政府、民间组织和私营部门，通过使用全面的国家数据，可以为亚洲和亚太地区的许多国家提供重要经验，特别是保持南南合作和其可持续性。过去十年来，中国在应对艾滋病毒疫情方面取得了重大进展，但政府对艾滋病毒疫情的反应并不稳定，在上世纪90年代初，疏忽是艾滋病毒传播的一个关键因素。近年来，更加坚定的政府应激反应使新的感染速度有所放缓，一些艾滋病毒感染者的生活质量也有所改善。

2018年9月，英国广播公司报道，中国新增感染病例增幅14%，仅第二季度就增加了4万例，且绝大多数是通过性传播的。卫生官员说，艾滋病毒感染者的人数每年增加10万人。中国每年新增病例占全球新艾滋病毒感染人数的3%，其中28%是与男同性恋之间的性行为感染的，这是新感染人数正在迅速增加的关键人群。在中国，大约6%的人感染了艾滋病毒。

这种流行病的主要特征是全国发病率较低，为0.037%，其中某些地区的患病率较高。2018年中国疾病控制中心报告称，有85万人感染了艾滋病毒，比2017年增长了12%，几乎是2010年的三倍。2011年至2015年，15岁至24岁的学生的新感染率每年增加三分之一，主要为男性间性行为传播。联合国艾滋病规划署（UNAIDS）预计2017年中国有76万人知道自己感染的情况，但官方并没有统计这些人或接受治疗的人数。2018年，开始接受抗逆转录病毒治疗的成人和儿童人数为13万人，其中近700人是儿童。

2018年，中国政府承诺加强艾滋病毒的预防和治疗，这是2017年国民卫生大会公共卫生的重要组成部分。尽管如此，许多人仍然没有意识到从云南省西南部注射药物的人转移到普通人群的风险正在增加。在治疗、护理和支持方面在中国是一项持续性的挑战。仅在2014年，有2.1万人死于与艾滋病相关的原因。艾滋病毒感染者的人数稳步增加，降低母婴传播率的进展进展缓慢，全国各地对解决艾滋病歧视方面也进展缓慢。60岁及以上人群中新感染情况的增加，来自中国疾病控制和预防中心(CCDC)的数据显示，2015年有15%的新感染病例属于这个年龄组。这可能反映了农民工外出打工时通过性工作者传播的一种趋势。

受艾滋病毒影响最严重的人群

虽然中国的艾滋病毒流行率相对较低，但艾滋病一直受到受影响人群的重点关注，一般人群也日益关注。疫情已从云南省的高风险注射吸毒者转变为普通人群，2014年，92%的新诊断是由于性传播。

随着年轻人越来越追求自由主义，人们对婚前性行为的态度也是如此。这一转变反映在2008年至2015年，15岁至24岁之间的新感染人数翻倍，男性同行感染者占这个年龄段新感染人数的82%。

有针对性的预防策略，对于在最危险群体中控制艾滋病传染以及解决关键人群面临的歧视，对于他们获得重要的艾滋病服务支持至关重要。

性工作者

性工作正成为中国艾滋病流行病学中的重要组成部分。中国国家艾滋病/性病控制和预防中心2014年的一项调查测算，59.3%的艾滋病毒阳性男性通过商业性活动感染了艾滋病毒。2015年，所有性工作者中的流行率为0.19%。因为性工作是非法的，中国还没有明确的性工作者数量，估计是有几百万人。大多数性工作者经常受到当局的打压，因此这部分群体对艾滋病毒认知及应对并不积极。

根据政府统计，近年来女性性工作者的患病率保持稳定，2014年为0.2%，但实际数字被认为在3%左右。中国没有男性性工作者的患病率报告，关于跨性别性工作者的数据有限，但有证据表明，该群体对艾滋病毒最为弱势。

男同性性行为人群

在中国，男同性性行为人群的艾滋病毒流行率继续上升，16至21岁男的年轻男性最近感染的风险尤其高。中国卫生和计划生育委员会指出，2016年该年龄组的发病率为7.7%。据估计，2013年男同性性行为人群每年都有超过四分之一的新感染病例。这一趋势在2014年继续存在，约25%的新感染与男性之间的性行为有关。

同性恋群体经常面临歧视，并隐藏自己的性身份。尽管有这种限制，一些研究工作正在进行和发表中。例如，2018年的一项研究表明，针对男性与男性发生性行为的预防计划，对亲密伴侣暴力的筛查和干预措施(IPV)。研究人员发现，最近的IPV与艾滋病毒的风险增加了4倍有关；IPV的经验是比其他一些人更容易感染的风险因素，38%归因于IPV。

对艾滋病毒状况的无知是男性与男性发生性行为的一个主要因素。2015年的一项研究发现，中国与男性发生性关系的高风险行为很高，大约45.7%的受访者报告与男性伴侣发生无保护的性行为，10.9%与女性伴侣发生无保护性行为，后者是一种日益增长的传播途径；大约38%的人用钱交换了性行为；来自11个城市中7个的数据表明，在与男性发生性关系的男性中，毒品使用率最高的地区的艾滋病毒流行率也最高。

重庆早期的一项研究发现，对与同性发生性行为的男性的艾滋病毒检测阳性率为58%，高于与正常异性性关系的男性44%。

年轻人

年轻人是是最受影响的人群之一。中国国家性病/艾滋病防治中心报告指出，2015年新感染病例的14.7%发生在15岁至24岁之间。尽管这些数字仍然相对较低，但人们越来越担心艾滋病毒流行对年轻一代的影响。事实上，年轻人新感染艾滋病毒的同比增长约为35%，而首次性行为的年龄越来越年轻。

了解这些人群之间的主要传播方式对于提供有效的支助和服务至关重要。研究发现，大多数被感染的年轻人都是男性（95%），其中70%的感染人都是在与同性发生性关系的年轻男性当中。因此针对年轻人的艾滋病教育是必要的，将年轻人纳入制订艾滋病防治政策和方案对解决该流行病极为重要。

农民工

移民往往会提高感染艾滋病毒的风险，非法移民可能会面临更复杂的问题，包括限制性的法律和政策、很少或无法获得医疗保健服务或社会保护、社会排斥。

人口流动中国是一个公共卫生的挑战。2016年估计有2.81亿人流动人口，其中大部分是从农村到城市。一项对上海农民工的研究发现，在过去的六个月里，只有13.8%的未婚女性流动人口持续使用避孕套。此外，对避孕套的了解并不足以改变这个群体的行为。

在东南亚地区，从中国南部到泰国的移民中的艾滋病毒流行率是一般人群的四倍。在云南进行的调查中，中国男性农民工和中国男性矿工的艾滋病毒患病率明显高于普通人群。

2016年的研究结果表明，在过去研究记录的与同性发生性关系的移民男性中，艾滋病毒的发病率较高，可能不是由于个人风险行为，而更多地与获得艾滋病毒预防干预措施的结构性障碍有关。

如果没有一种全面的的方法来处理流动人口的艾滋病毒和健康需求，干预措施可能就无法触及这些流动人群。

注射毒品的人

在250多万注射毒品(有时被称为PWID)的人中，大约有6%的人感染了艾滋病毒。其中，大约87%的人报告了安全注射的做法。虽然这些关键人群的流行率相对较低，但也严重缺乏减少危害方案。2014年，据报道，阿片类药物替代疗法的覆盖率仅占所需水平的65%。然而，每年分发的针头和注射器数量为204头，略高于卫生组织建议的每年200头清洁针头。

中国的艾滋病毒检测和咨询

近年来在加强艾滋病毒咨询和检测方面取得了显著成绩，已经发现了大量新的感染病例。2008年至2017年，艾滋病毒检测设施的数量从7600增加到30500，艾滋病毒检测的年数量从4500万人增加到2.01亿人，即3.4%增加到14.5%，报告的新感染人数从56350人增加到134500人以上。

2017年一项具有里程碑意义的研究发现，以患者为中心的简化艾滋病毒检测和治疗方法，改善了艾滋病毒患者的临床结果。该方法旨在简化艾滋病治疗途径，最大限度地减少从艾滋病检测到开始治疗之间的医院或诊所就诊时间和次数，这是人们没有继续接受艾滋病治疗的一个主要原因，也是中国艾滋病感染者发病率的一个主要原因。

在简化之前，只有43%在全国部分地区获得初步阳性结果的患者后来得到了确认性诊断，只有57%的新诊断患者在诊断后6个月内接受了CD4测试。2017年，卫生指南仍然要求CD4计数来确定是否应该开始治疗时，80%的新确认为HIV阳性的人没有得到及时的抗逆转录病毒治疗。

创新的干预措施和政策变化，如本研究中尝试的方法，以确保实现快速通道目标。

社交媒体正在鼓励中国同性恋男性接受艾滋病毒检测

尽管新的艾滋病毒感染率正在上升，但这一组患者的检测率仍很低。对男同性恋者的歧视是很常见的，也是一种强烈的威慑作用。在完成这项研究的1200名受访者中，过去一个季度的艾滋病毒检测人数增加了8.9%。研究人员估计，大约有1万名男性看到了这一活动，其中大约一半至少接受过一次艾滋病毒检测。

中国的艾滋病毒预防方案

在过去的十年中，全国各地的艾滋病毒预防方案不断发展起来。减少艾滋病毒的性传播一直是中国预防规划的重点。2017年，中国稳步推进全面预防方案，针对感染艾滋病毒风险更大的关键人群，包括女性性工作者和与同性发生性关系的男性。

避孕套的可用性和使用情况

过去十年来，避孕套在中国已经越来越广泛，但使用量仍然相对较低。使用不仅取决于可用性，性别之间的权力动态是一个重要因素，当这种动态与交叉的脆弱性交织在一起时，谈判可能会很困难。心理和个性因素也会影响安全套的持续使用——例如，孤独、抑郁和自卑的人不太可能持续使用安全套。

艾滋病毒意识、教育和性教育的方法

认识到学校性教育的重要性，中国在过去40年里颁布和执行了各种法律和政策。全面的性教育并不是中国学校课程的强制性部分。在向儿童和年轻人学习性教育的各个方面时，大部分课程都是由非政府组织或私立学校就试点项目进行的。

2016年，为了应对年轻人中新的艾滋病毒感染率的上升，中高中学生必须参加性教育课程。这是一个大胆的步骤，将性教育从大学年龄或以上的学生身上扩展出来。在2017年发表的一项对中国大学生调查中，44%的受访者在大学前没有接受过任何性健康教育。2017年，中国继续在大学开展艾滋病毒预防试点，将艾滋病毒教育纳入教学计划和年度评估，并扩大试点经验。政府资助的大学青年学生艾滋病毒/艾滋病预防基金组织了专家和名人，继续开展“青年红丝带进入校园”的活动，并在中学阶段修订了“艾滋病毒/艾滋病预防教育电影”。上述所有措施进一步加强了学校的艾滋病预防和性健康教育。

2018年的一项研究发现，几乎所有的被调查学校都没有足够全面的性教育，缺乏暴力、性别、权利、性行为、性取向、性取向、避孕套、避孕和堕胎等主题。同样的研究还发现，相当一部分教师不了解性教育的好处，实施性教育的两个关键障碍是缺乏专门的教师培训和教学资源不足。

防止母婴传播(PMTCT)

2015年，中国全面覆盖了PMTCT。2017年，“消除艾滋病毒/艾滋病母子传播：中国正在采取行动”倡议启动。该试点项目由世界卫生组织的消除标准为指导，该标准支持制定一项消除艾滋病毒、梅毒和乙型肝炎母婴传播的综合方案。

虽然中国已经实现了PMTCT的全面覆盖，但服务并没有纳入一般的妇幼保健服务，而且保健工作者在与社区团体合作实现消除母子传播目标方面的经验非常有限。

近年来，中国预防母婴传播方案迅速发展，母婴传播是国家艾滋病毒反应的重点。这使艾滋病毒感染新生儿从2001年的7.4%减少到2014年的6.1%。截至2017年底，有5500多名15岁以下儿童接受抗逆转录病毒治疗。

对中国不同省份的研究发现，即使在存在PMTCT方案的地方，由于缺乏抗逆转录病毒治疗等问题，服务也并不总是有效的。例如，2013年广东的一项研究发现，由于艾滋病毒阳性母亲缺乏抗逆转录病毒药物，PMTCT项目未能达到其目标，60.2%接受抗逆转录病毒药物，只有48.2%在怀孕期间接受抗逆转录病毒药物。其他研究表明，在许多情况下，孕妇不知道或不了解艾滋病毒的产前卫生服务。

然而，当PMTCT方案得到充分的资金资助和实施时，它们已被证明是有效的。例如，艾滋病毒流行率相对较高的贺州市于2003年开始实施PMTCT方案。贺州将PMTCT干预措施纳入常规妇幼保健，开展广泛的宣传和社会动员活动，提高群众意识，增强卫生人员有效实施服务的能力。自2009年以来，没有报告孕妇感染艾滋病毒的儿童感染艾滋病毒的病例。

预防受感染的献血和输血

20世纪90年代初，粗糙的血站采血加剧了艾滋病毒流行。据估计，2005年通过血液制品传播的艾滋病毒占感染人数的10%。2010年，所有收集到的血液制品都接受了艾滋病毒筛查。2014年，政府提供10亿人民币改善献血服务。

截至2015年，大多数血液中心使用的检测方法检测到了艾滋病毒抗体，这些抗体只有在感染艾滋病毒22天后才会出现。这些测试正逐渐被更快速的测试所取代，这些测试只需11天就能显示结果。据估计，这些测试将减少一半的艾滋病毒通过输血传播。

减少伤害程度

中国有许多减少伤害的干预措施，以减少注射毒品者中艾滋病毒的传播。截至2014年底，在28个省有760多家阿片替代疗法诊所，为18万多人提供治疗方案。据报道，接受OST的HIV感染者人数从2013年的0.13%略微下降到2014年的0.12%。据报道，在中国西昌市实施的减少伤害计划已经将注射毒品人群中新感染艾滋病病毒的人数减少了75%。

2014年，在14个省开展了814个针头和注射器交换项目。56000多名吸毒者参加了交流方案，分发了1100多万支针头和注射器。这相当于每人204支干净的注射器。联合国艾滋病规划署和世界卫生组织认为每人200支及以上的注射器覆盖率较高。

2014年的一项研究发现，在中国艾滋病高发省份广西，69%的艾滋病病毒感染者通过注射毒品呈阳性。为注射毒品的人提供有针对性的干预方案对于降低他们感染艾滋病毒的风险至关重要。然而，在强制戒毒所成为常态的许多地方，实施减少伤害方案仍然是一个巨大的挑战。

中国抗逆转录病毒治疗的可用性

中国遵循2016年世界卫生组织（WHO）的HIV治疗指南，该指南建议为所有HIV感染者提供治疗，无论CD4计数如何。2016年，中国承诺为所有艾滋病病毒感染者提供抗逆转录病毒治疗，覆盖率从2015年的67%提高到2017年的80%。截至2017年底，接受治疗的总人数为60.95万人，当年开始接受治疗的人数为13.15万人。2017年在中国发表的一项全国性研究得出结论，开始低CD4计数的人立即接受抗逆转录病毒治疗，总死亡率降低63%——证实了早期治疗对改善健康状况的益处。

HIV耐药性（TDR）

与其他中低收入国家一样，艾滋病病毒耐药性正在严重威胁着艾滋病治疗，在这些国家，薄弱的卫生系统和难以获得监测和诊断，使得管理艾滋病病毒更具挑战性。关于中国艾滋病病毒耐药性的数据很少。2010年发表的一项研究得出结论，在从未接受过治疗的人群中，耐药性在2004年和2005年为3.8%。

2015年，16-25岁的抗逆转录病毒新诊断人群治疗组的TDR发生率占3.6%，但没有关于25岁以上HIV感染人群TDR的最新数据。

2011年至2013年在山东进行的一项研究，对已经开始或新接受艾滋病毒抗逆转录病毒治疗(ART)的患者进行了耐药性测试。其目的是确定年龄、性别、种族、婚姻状况、受教育程度、传播途径和治疗状况对耐药性的影响。研究发现，艾滋病毒耐药率很低，在危险因素中，初级抗性（发生在人们以前未接受治疗时）占总病例的20%，而其他因素没有显著影响。然而，它确实建议低教育水平和二线治疗的患者应持续监测。并提出，当人们积极参与的抗药性检测可以有效预防耐药性的发展和传播。

【原文】

HIV and AIDS in China

KEY POINTS

• l China accounts for 3% of new HIV infections globally each year. In 2018, a 14% rise in new infections was reported, with 40,000 in the second quarter alone.

• l The majority were transmitted through sex in the general population. In 2017, China steadily promoted comprehensive prevention programmes targeting female sex workers and men who have sex with men.

• l The lack of comprehensive sexuality education is a major barrier to an effective response and open discussion of sex and sexual health is still taboo.

• l Although significant progress has been made in tackling the HIV epidemic, HIV activists, non-governmental organisations (NGOs) and civil society are still being silenced.

China’s multi-sectoral approach to HIV, which engages government, civil society and the private sector and draws on comprehensive national data, can provide important lessons for many countries in Asia and the Pacific and beyond, particularly for south-south collaboration and sustainability.

China has made substantial progress in tackling its HIV epidemic in the last decade but the national response to the HIV epidemic has been anything but steady, with negligence being a critical factor in the spread of HIV in the early 1990s. In recent years, a more committed national response has meant that the rate of new infections has slowed and that quality of life for some people living with HIV has improved.

In September 2018, the BBC reported a 14% rise in new infections, with 40,000 in the second quarter alone. The majority were transmitted through sex in the general population. Health officials say that the number of people living with HIV has increased by 100,000 each year.

China accounts for 3% of new HIV infections globally each year, and 28% of these are among men who have sex with men (sometimes referred to as MSM), a key population where new infections are rapidly increasing. Around 6% of people who inject drugs in China are living with HIV.

The epidemic is largely characterised by a low national prevalence of 0.037%, with certain regions having higher prevalences.

In 2018, China’s Centre for Disease Control reported that 850,000 people were living with HIV, up 12% on 2017, and almost three times as many as in 2010. Between 2011 and 2015, new infections increased by a third each year among students aged between 15 and 24, mostly among adolescent boys and men who have sex with men.

UNAIDS estimated that 760,000 people in China knew their status in 2017, however there are no official government estimates for those that know their status, or the number of people on treatment.6 In 2018, the number of adults and children starting on antiretroviral treatment was 130,000, of those almost 700 were children.

In 2018, China’s political leadership pledged to strengthen HIV prevention and treatment, acknowledging that it was an essential part of public health at the National Health Assembly in 2017 Despite this many people are still unaware of the increased risk that has shifted from people who inject drugs in the southwestern province of Yunnan to the general population.

Treatment, care and support challenges prevail in China. In 2014 alone, 21,000 people died from AIDS-related causes. The number of people living with HIV on treatment has steadily increased, however, progress in reducing mother-to-child transmission rates is still regarded as slow. Progress has also been slow in addressing the high levels of stigma and discrimination people living with HIV experience across the country.

Also of interest is the rise of new infections among people aged 60 and over. Figures from the Chinese Center for Disease Control and Prevention (CCDC) show 15% of new infections in 2015 were among this age group. This may reflect a trend in migrant workers for visiting sex workers while away from home.

Populations most affected by HIV in China

Though HIV prevalence in China is relatively low, the epidemic has long been a major concern for key affected populations within the country, and is now of growing concern for the general population. The epidemic has shifted from high-risk injecting drug users in the southwestern province of Yunnan to the general population. In 2014, 92% of new diagnoses resulted from sexual transmission.

As young people become increasingly liberal, so do attitudes towards premarital sex. This transformation is reflected in the number of new infections in people aged between 15 and 24 years doubling between 2008 and 2015, with men who have sex with men making up 82% of new infections in this age group.

Targeted prevention strategies are critical to control the epidemic among the most at risk groups as well as addressing the stigma and discrimination that many people from key populations face on a daily basis, preventing them from accessing vital HIV services.

Sex workers

Sex work is becoming a more significant part of the overall epidemiology of HIV in China. A 2014 survey by the Chinese National Center for AIDS/STD Control and Prevention estimated that 59.3% of the surveyed HIV-positive men had contracted HIV through commercial sexual activity.

Prevalence of HIV among all sex workers was 0.19% in 2015, the last update. There’s no agreed number of sex workers in China but most estimates are that there are several million. Sex work is illegal and most sex workers experience regular humiliation and abuse by the authorities which directly undermines the country’s HIV response targeting this vulnerable population.

Estimated prevalence among female sex workers appears to have remained stable in recent years, at 0.2% in 2014 according to government statistics although the actual figure is thought to be around 3%. China does not report on prevalence among male sex workers and there is limited data on transgender sex workers, but evidence suggests that this group has the highest vulnerability to HIV.

Even though the government has set up programmes to prevent HIV, including the rollout of condoms and HIV testing, the police consider use of condoms as evidence of sex work, which means that sex workers’ possession and use of condoms (or lack of) puts them either at risk of abuse or HIV.

Being abused and at risk of arrest for carrying condoms seriously impedes wider public health efforts to improve coordination and delivery of services. Making sex work and related activities legal would be a step in the right direction.

This kind of approach towards sex workers not only seriously reduces opportunities for people working in HIV prevention to coordinate with the police and public health departments but deters entertainment venues from publicly displaying condoms on their premises. This results in sex workers being less likely to use condoms.

Even though sex workers, together with other marginalised groups are seen as immoral by many in Chinese society, police actions have been so extreme as to raise concerns in society for the well-being of sex workers.

Men who have sex with men

HIV prevalence among men who have sex with men (sometimes referred to as MSM) continues to rise in China, with young men who have sex with men between the ages of 16 and 21 being particularly at risk of recent infection.20 China’s Health and Family Planning Commission officially estimated prevalence among this group to be 7.7% in 2016, the most recent data available.

In 2013, men who have sex with men were estimated to represent over a quarter of new infections each year. The trend continued in 2014, with around 25% of new infections estimated to be linked to sex between men.

Although homosexual sex has been legal since 1997 and has not been on the official list of mental disorders since 2001 economic and cultural factors mean that this group often face stigma and discrimination and hide their sexual identity. This hostile environment is preventing a greater understanding of the epidemic in China among men who have sex with men.

Despite this limitation, some research is being conducted and published. For example, a 2018 study showed that prevention programmes aimed at men who have sex with men should include screening and interventions for intimate partner violence (IPV). Researchers found that recent IPV was linked to a fourfold increase in the risk of HIV infection.

They also found that experience of IPV was a more significant risk factor for infection than several others usually associated with a high risk of HIV infection, with 38% being attributed to IPV.

Ignorance of HIV status is a major factor among men who have sex with men. A 2015 study found high-risk behaviour among men who have sex with men in China to be high. Around 45.7% of respondents reported having unprotected sex with male partners and 10.9% with female partners, the latter being an increasing route of transmission. Around 38% had exchanged money for sexual activities. Data from seven of the 11 cities suggests that districts with highest rates of illicit drug use among men who have sex with men also shared the highest HIV prevalence.

However, an earlier study in Chongqing City, which has a high HIV prevalence among men who have sex with men, found that HIV testing was actually higher for men who have sex with men (58%) than the general population (44%).

Young people

One of the growing key affected populations in China is young people. China's National Centre for STD/AIDS Prevention and Control reports 14.7% of new infections in 2015 were among people aged 15 to 24. Despite these figures still being relatively low, there is increasing concern about the impact of the HIV epidemic on younger generations. Indeed, the year-on-year growth rate of new HIV infections among young people is around 35%, with the age of sexual debut becoming younger.

Understanding the main mode of transmission among this population is crucial to providing effective support and services. It has been found that the majority of young people infected are male (95%), and 70% of those infections have been among young men who have sex with men. It is therefore vital that HIV services and education are tailored to younger generations and key affected groups within these younger populations.

Including young people in the design and formulation of HIV policies and programmes is of major importance in tackling the epidemic. A user-centred approach would also challenge stigma and discrimination at the same time as increasing knowledge of HIV and reducing risk-taking behaviour.

Migrant workers

Migration often results in people being in situations where they are at heightened risk of HIV. Undocumented migrants can face complex problems, including restrictive laws and policies, little or no access to healthcare services or social protection, social exclusion and vulnerability to exploitation. They also suffer from stigma and discrimination, and social exclusion.

Internal migration is a public health challenge in China. In 2016, an estimated 281 million people migrated within the country, mostly from rural to urban locations. A study of migrant factory workers in Shanghai found only 13.8% of unmarried female migrants reported consistent condom use in the past six months. Additionally, being knowledgeable about condoms was not enough to change behaviour in this group.

In the South-East Asian region, HIV prevalence among migrants from southern China to Thailand is up to four times that of the general population. Significantly higher HIV prevalence was found among Chinese male migrant workers and Chinese male miners compared to the general population in surveys conducted in Yunnan.

Study findings from 2016 suggest that higher HIV prevalence among migrant men who have sex with men documented by past studies may not be due to individual risk behaviours and have more to do with structural barriers to accessing HIV prevention interventions.

Without a comprehensive, rights-based approach to dealing with the HIV and health needs of migrant populations, interventions may not reach these mobile populations.

People who inject drugs

In violation of international human rights, China still has the death penalty for a range of drug crimes. Drug offences are estimated to make up a significant portion of executions in the country. This extreme climate of fear prevents many drug users from accessing HIV prevention and treatment.

Of the over 2.5 million people who inject drugs (sometimes referred to as PWID), around 6% are living with HIV. Of these, around 87% report safe injecting practices.

Although reported prevalence among this key population is relatively low, harm reduction programmes are seriously lacking. In 2014, it was reported that coverage of opioid substitution therapy was just 65% of what was needed. However the annual number of needles and syringes distributed per person was 204, just above the WHO recommendation of 200 clean needles per person per annum.

HIV testing and counselling (HTC) in China

China promotes HIV testing and scale up, and has made notable achievements in strengthening HIV counselling and testing in recent years. As well as more testing, a large number of new infections have been identified. Between 2008 and 2017, the number of HIV testing facilities increased from 7,600 to 30,500; the annual number of HIV tests increased from 45 million to 201 million (from 3.4% to 14.5% of the whole population), and due to more testing, the number of new infections reported increased from 56,350 to over 134,500.

In 2017, a landmark study found that a patient-centred approach to streamlined HIV testing and treatment resulted in improved clinical outcomes for people living with HIV.

The approach aims to streamline pathways to HIV treatment, minimising the time and number of hospital or clinic visits between HIV testing and treatment initiation - a major reason why people do not remain in HIV care, and a major contributor to morbidity of people living with HIV in China.

Prior to streamlining, just 43% of patients who had received an initial positive result in some parts of the country were later given a confirmatory diagnosis. On top of this, just 57% of people newly diagnosed received a CD4 test within six months of diagnosis. In 2017, when national health guidelines still required a CD4 count to determine whether a person should start treatment, 80% of people newly identified as HIV-positive did not receive timely antiretroviral treatment.

Given the population growth rate in China – innovative interventions and policy changes such as the approach trialled in this study are needed to ensure Fast-Track targets are met.

Social media is encouraging gay Chinese men to get tested for HIV

Testing rates remain low among this group although new HIV infections are on the rise. Stigma and discrimination towards gay men is common and a strong deterrent. However, co-created health awareness campaigns have the potential to reduce the stigma around testing for HIV.

Among the 1,200 respondents who completed the study, there was an 8.9 per cent increase in HIV testing over the past quarter. The researchers estimate that the campaigns were seen by around 10,000 men, around half of whom had tested for HIV at least once as a result.

HIV prevention programmes in China

HIV prevention programmes have consistently developed across the country in the last decade. Reducing sexual transmission of HIV has been the focus of China’s prevention programming for some time since this is the main transmission route. In 2017, China steadily promoted comprehensive prevention programmes targeting key affected populations at greater risk of HIV including female sex workers and men who have sex with men.

Condom availability and use

Condoms have become more widely available in China in the last decade, however, use remains relatively low (when compared with other countries) as they are generally regarded as contraceptives and a woman’s responsibility. Open discussion of sex and sexual health is taboo which means that reaching people with sexual health information and education is difficult.

A 2016 report – the Condom Quandary - on the impact of law enforcement practices on effective HIV prevention among male, female, and transgender sex workers in China showed the negative effect that laws and law enforcement practices have on sex workers’ ability to access and carry condoms.

This is further reflected in government data which shows that consistent condom use among MSM has remained at around 45% for a number of years.

Use is not only dictated by availability. Power dynamics between and among genders are an important factor, and when this is compounded by intersecting vulnerabilities condom negotiation can be difficult. Psychological and personality factors can also influence consistent condom use – for example, lonely people with depression, and low self-esteem are less likely to use a condom consistently.

HIV awareness, education and approach to sex education

Recognizing the importance of school-based sexuality education, China has issued and enforced various laws and policies over the past four decades. However, comprehensive sexuality education is not a mandatory part of the school curriculum in China. Where children and young people are taught aspects of sex education, most lessons are carried out by non-governmental organisations or private schools on pilot projects.

In 2016, in an effort to combat the rise in new HIV infections among young people, China announced that middle and high school students were required to attend sex education classes. This was a bold step, expanding sex education out from just students of university age or above.

In a survey of Chinese university students published in 2017, 44% of respondents had not received any sexual health education before university.

In 2017, China continued to carry out HIV prevention pilots at universities, incorporating HIV education into teaching plans and annual assessments, and scaling up the pilot experiences. The government-funded University Young Students' HIV/AIDS Prevention Fund organised experts and celebrities to continue with 'Youth Red Ribbon into the Campus’ activities and revised the 'HIV/AIDS Prevention Educational Film’ at the middle school stage. All the above measures further strengthened the school-based HIV/AIDS prevention and sexual health education.

A 2018 study found that almost all of the surveyed schools did not have sufficiently comprehensive sexuality education, with coverage of topics such as violence, gender, rights, sexual behaviour, sexual orientation, condom, contraception and abortion lacking.

The same study also found that a significant number of teachers don’t understand the benefits of sexuality education and need to be made aware of the scientific evidence. Two of the key barriers to implementing sexuality education are a lack of specialised teacher training and inadequate teaching resources.

Prevention of mother-to-child transmission (PMTCT)

In 2015, China achieved full coverage of PMTCT. In 2017, the 'Eliminating HIV/AIDS mother-to-child transmission: China is in action’ initiative was launched. The pilot project was guided by the World Health Organization's elimination standard which supports the development of an integrated programme to eliminate mother-to-child transmission of HIV, syphilis and hepatitis B.

Although China has achieved full coverage of PMTCT, services are not integrated into general maternal and child health services, and healthcare workers have very limited experience in working with community groups to achieve targets around elimination of mother-to-child transmission.

China’s preventing mother-to-child transmission programme has substantially developed in recent years, with mother-to-child transmission a critical concern of the national HIV response. This has resulted in a reduction in HIV-infected newborns from 7.4% in 2001 to 6.1% in 2014.58 As of the end of 2017, there were over 5,500 affected children under the age of 15 receiving antiretroviral treatment.

Despite this, studies of different Chinese provinces have found that, even where PMTCT programmes exist, services are not always effective due to issues such as a lack of antiretroviral treatment. For example, a 2013 study in Guangdong found PMTCT programmes failed to meet their objectives due to a shortage of antiretrovirals for HIV positive mothers, with 60.2% receiving antiretrovirals and only 48.2% receiving these during pregnancy.

Other research suggests that, in many cases, pregnant women are unaware of or lack knowledge of HIV antenatal health services.

However, when PMTCT programmes are fully funded and implemented they have been shown to be effective. For example, Hezhou City, where HIV prevalence is relatively high, began implementing PMTCT programmes in 2003. Hezhou integrated PMTCT interventions into routine maternal and child healthcare, carried out extensive publicity and social mobilisation campaigns to improve people’s awareness and enhanced the capacity of health staff to implement services effectively. Since 2009, no cases of HIV infection among children born to pregnant women with HIV have been reported.

Prevention of infected blood donation and transfusion

China’s HIV epidemic was profoundly marked by negligent blood donation activities in the early 1990s, which led to a dramatic increase in the spread of HIV across China.

It was estimated that HIV transmission through blood products accounted for 10% of infections in 2005. Serious efforts have been made to prevent these incidences from ever happening again. In 2010, the government announced that all collected blood products were screened for HIV. Funding to improve blood donation services increased, with the government providing 1 billion RMB (approx. US$145,000,000) in 2014.

Although blood donations are now tested for HIV, as of 2015 the tests being used at the majority of blood centres detected HIV antibodies, which only register after 22 days of HIV infection. These tests are gradually being replaced by more rapid tests, which show results after only 11 days. It is estimated these tests will cut transmission of HIV through blood transfusion in half.

Pre-exposure prophylaxis (PrEP)

The WHO recommendation on oral PrEP has not yet been adopted in China’s national guidelines. According to PrEPWatch, as of December 2018, the estimated number of PrEP users was between 800 and 1,000. Though there are ongoing PrEP demonstration (for men who have sex with men) and implementation (for at-risk adults and adolescents) projects, the operating environment is still extremely hostile, with reports of shipped PrEP medications getting confiscated by Chinese Customs.

However, the actual number of people taking PrEP informally could be far higher as generic drugs are now available to buy from online suppliers or elsewhere. An article in China Daily in 2017 suggested that large numbers of gay Chinese tourists were buying PrEP in Thailand.

China has not yet licensed tenofovir for prevention, however Blued.com, its biggest gay dating app with more than 23 million users, reports an upsurge of interest in PrEP.

However, men who have sex with men could benefit from more information around PrEP to increase uptake and curb new HIV infections in this group. Just one-quarter (26%) of men who have sex with men surveyed in 2017 said they would use PrEP should it become more accessible, but most (56.8%) participants doubted its efficacy as an HIV prevention method.

In this nationally representative survey of 4,581 men, it was also revealed that only 22.4% of participants had heard of PrEP before taking the survey. The authors note that there is an urgent need to develop targeted information and PrEP advertising campaigns for gay men in China.

National surveys have estimated HIV prevalence among Chinese men who have sex with men to be increasing rapidly, from 1.5% in 2005 to 8% in 2015. Other studies estimate even higher HIV prevalence among urban gay men (9.9%), with some cities reporting prevalences near 20%. Over a quarter of HIV diagnoses in China are among MSM, more than three times the rate of new diagnoses for MSM in other countries. PrEP has the potential to reverse this trend.

Given the high response rate using this internet-based survey, the study authors suggest there is potential to provide information and education around PrEP on the Internet – with a particular focus on boosting knowledge of PrEP effectiveness.

Harm reduction

China has a number of harm reduction interventions to reduce the transmission of HIV among people who inject drugs. By the end of 2014, there were over 760 opioid substitution therapy (OST) clinics in 28 provinces offering programmes to over 180,000 people. It was reported that the number of people living with HIV receiving OST dropped marginally from 0.13% in 2013 to 0.12% in 2014.

Harm reduction programmes in Xichang City in China are reported to have cut the number of new HIV infections among people who inject drugs by 75%.

In 2014, 814 needle and syringe exchange projects were operating across 14 provinces. More than 56,000 drug users participated in the exchange programmes and more than 11 million needles and syringes were distributed. This equates to 204 clean syringes per person. UNAIDS and WHO considers 200 syringes per person and above as high coverage.

A 2014 study found that 69% of people living with HIV in Guangxi, a province with high HIV prevalence in China, became positive through injecting drugs. Providing targeted intervention programmes for people who inject drugs is vital for reducing their risk to HIV. However, implementing harm reduction programmes remains a huge challenge in many places where compulsory drug detention centres are the norm.

Antiretroviral treatment availability in China

China follows the 2016 World Health Organization (WHO) guidelines for HIV treatment, which recommends provision for all people living with HIV regardless of CD4 count. In 2016, China committed to providing antiretroviral treatment for all people living with HIV which increased coverage from 67% in 2015 to 80% in 2017. As of the end of 2017, the total number of people on treatment was 609,500, with 131,500 starting on treatment in that year.

A nationwide study in China, published in 2017, concluded that starting people with low CD4 counts on immediate antiretroviral treatment reduced overall mortality by 63% – confirming the benefit of early treatment for improved health outcomes.

HIV drug resistance

HIV drug resistance is a serious emerging threat to the global scale-up of HIV treatment access in China, as it is in other low- and middle-income countries where weak health systems and poor access to monitoring and diagnostics make managing HIV more challenging.

Little data is available on HIV drug resistance in China. A study published in 2010 concluded that the overall prevalence of transmitted drug resistance (TDR) among people who had never taken treatment (also called ART-naïve) in 2004 and 2005 was 3.8%.

Unpublished data suggests that the rate of TDR among 16–25 year-old ART-naïve newly diagnosed people was 3.6% in 2015, however, there is no recent data on TDR among HIV-infected populations above the age of 25.

A study running from 2011 to 2013 in Shandong Province, conducted drug resistance testing on patients who were already on or new to HIV antiretroviral therapy (ART). The aim was to determine the effects of age, gender, ethnicity, marital status, educational level, route of transmission and treatment status on drug resistance.

It found the prevalence of HIV drug resistance to be low, and among the risk factors, primary resistance (which happens when people have not previously been on treatment) accounted for 20% of the total cases while other factors had no significant effect. However, it did suggest that patients with a low educational level and those on second-line treatment should be monitored continuously. It also put forward that drug resistance testing could effectively prevent the development and spread of drug resistance when people actively participated.