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. 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.

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.

I was having a drink with a client in a bar when a group of policemen burst in and began checking everyone’s ID cards. When a policeman saw me, he said: ‘You’re the bar’s playboy [a term for a male sex worker] aren’t you?' I said I wasn’t, but he didn’t believe me, and he snatched the bag I was carrying and rifled through it, and he found a lot of condoms inside, and he stared at me and said: 'You’re still not admitting you’re selling sex? Then why are you carrying all these condoms?’ And with that, I and many others were taken to the local public security bureau that night.

- Liu Chang, a male sex worker

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. 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.

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.

I found the images and videos interesting and informative, unlike the text-based materials we were shown in the official disease control centre. They are creative and funny. It’s a good reminder… you become more aware of HIV tests after seeing the images.

- Sam Ding, a survey participant from Guangzhou

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.

We have limited resources to contain HIV. Shandong Province has over 100 counties, and each county has a population of over one million people. The least populous county still has 300,000 to half a million people. Yet each county has only one to three CDC staff dedicated to HIV prevention.

- Dr. Liao Meizhen, Shandong Center for Disease Control and Prevention (CDC), China

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.

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.

Sex education faces great challenges in China. At Tsinghua [University], students take sex education classes where they learn basic knowledge about sex safety, condom use, etc. As far as I know, this is the first time most of my students have ever taken such a class.

- Jing Jun, a professor of sociology at Beijing's Tsinghua University

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. 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.

Peace Rehab Centre This short film about the Peace Rehab Centre - a community-based treatment centre piloted by AIDS Care China - shows how it’s changed lives through a series of personal stories.

Community based treatment centre for drug users Video of Community based treatment centre for drug users This short film about the Peace Rehab Centre - a community-based treatment centre piloted by AIDS Care China - shows how it’s changed lives through a series of personal stories.

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 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.

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Restrictions on civil society in China make it very challenging for people to organise, occupy civil space and claim human rights in general, and even more so for members of key populations who are particularly vulnerable to HIV, or living with HIV.

In the face of an increasingly vocal public and more visible civil society activity in recent years, the government has further restrained peoples’ right to the freedoms of association, peaceful assembly and expression under the guise of ‘protecting national security and preventing terrorism’.

[2017] …saw a marked increase in the use of detention, show trials and forced confessions, with human rights lawyers notably targeted. New punishments were introduced in late 2017 for such broad offences as disrespecting China’s flag, national anthem and emblem. This fresh crackdown came as President Xi Jinping moved to consolidate his position at the helm of China’s global power.

- Andrew Firmin, Editor-in-Chief, Civicus

Civil society organisations (CSOs), activists and lawyers have been harassed, arbitrarily arrested and detained. Although protests are common in China, officially they are banned in most of the country and are particularly dangerous to hold in some regions, including Tibet, where they are regularly broken up and protestors are beaten. In the Xinjiang autonomous region in the north west, civic space is under extreme pressure: a counter-terrorism operation launched in 2014 has led to an almost total denial of free expression.

The Internet is monitored and censored more and more, and in 2016, a proposed new cybercrime law threatened to increase the surveillance and criminalisation of legitimate online expression even more.

China has some of the world’s highest burden for TB, multi-drug resistant TB and TB/HIV coinfection. In 2017, estimated TB-related deaths among people living with HIV stood at 1,800. China continues to follow the National Work Plan for the Implementation of the co-infection of Mycobacterium Tuberculosis and HIV (Trial) and to screen people with HIV – both people living with HIV and those newly diagnosed – for TB. TB patients are also being tested for HIV in the 294 key counties (districts) for the prevention and control of HIV and TB coinfection.

Human rights

China’s growing global power has led to its human rights violations becoming more visible, including at the United Nations, where in 2018 it tried to block its critics. China was again singled out for punishing those who speak out to defend human rights, and in March advanced a Human Rights Council (HRC) resolution on a regressive approach whereby states do not pursue accountability for serious human rights violations but merely engage in ‘dialogue’. In addition, there is no role for independent civil society, only governments, and a narrow role for the UN itself.

Although significant progress has been made in tackling the HIV epidemic, many voices in China are still being silenced, including HIV activists, non-governmental organisations (NGOs) and civil society projects. This has had significant repercussions for people living with HIV and the increasing number of those at risk.



The government remains cautious in its dealings with the majority of human rights groups and NGOs working in China, which severely limits their capacity. Harassment, detention and censorship are just some of the challenges HIV activist groups have faced in the past.



That said, some provincial HIV regulations include provisions to uphold the rights of people living with HIV. For example, regulations in Yunnan Province prohibit refusal of medical care for people living with HIV and prohibit employment units from discriminating against people living with HIV and their family members.

However, this province has also introduced regulations that restrict rights, such as requirements for mandatory HIV testing before marriage in high HIV prevalence regions and HIV testing every six months for entertainment venue workers. Furthermore, policies that protect the rights of people living with HIV are all too frequently undermined by state authorities such as the police. This also leads to increased stigma and discrimination across Chinese society.

Stigma and discrimination

Stigma and discrimination are still major barriers to the scale up of prevention, treatment and care of key populations and their sexual partners in China, particularly towards men who have sex with men. Though homosexuality was decriminalised in 1997, the country’s laws do not protect people from discrimination on the basis of sexual orientation or gender identity, and same-sex partnership is not legal. Law enforcement negatively affects public health interventions and impedes behaviour change where it’s most needed.

The 2009 China Stigma Index study, the most recent available, found HIV-related discrimination in employment, education and healthcare to be widespread. Of the 2,000 people living with HIV surveyed, 42% reported having faced some type of HIV-related discrimination and 12% had been refused medical care. Around 15% said they had been refused employment or a work opportunity and 7% had been forced to move or refused accommodation due to their HIV status. Of the female respondents, around 12% had been pressured into terminating a pregnancy by medical staff or a family planning department due to their positive status.

In March 2018, the Beijing International Film Festival pulled an award-winning film that features a homosexual relationship, ‘Call Me By Your Name,’ because it didn’t meet government approval. A few months later in Hong Kong, the highest court ruled that the government’s denial of a visa and associated benefits to the same-sex spouse of a legal resident amounted to discrimination, a small but significant win. However, around the same time, the Hong Kong authorities moved a selection of 10 children’s books with LGBT themes to the ‘closed stacks’ in public libraries.

Legal and punitive barriers

HIV programmes are severely limited by the criminalisation of key affected populations, mainly sex workers and people who inject drugs. It is illegal in China to engage in sex work, with sex workers facing compulsory detention for reasons of ‘re-education’ and punishment. Sex workers are one of China’s key affected populations but HIV programmes to increase awareness and provide support are restricted by the punitive laws surrounding their work.

In recent years, China has been increasing investment in its HIV response. In 2017, China's fiscal expenditure was almost 7 billion Yuan Renminbi (US$ 1 billion) on its HIV response, an increase of more than 5.4% from 2016. In 2015, the state set up a special China AIDS Fund for Non-governmental Organization (CAFNG) to support social organisations in participating in the HIV response.

China is faced with the increasing challenge of providing more targeted prevention programmes to key affected populations such as men who have sex with men, people who inject drugs and young people.

China has made substantial progress with regard to funding its HIV response as 99% of funding came from domestic sources in 2015. This is relatively encouraging when considering the sustainability and longevity of many of the national HIV and AIDS commitments. However, without increased finance, HIV drug and other resource shortages will continue, preventing those most in need of treatment from accessing it.

A 2016 study of Shandong Province suggests that there is a long way to go before it achieves UNAIDS’ 90-90-90 targets. Research found only 60% of people with HIV were diagnosed, 42% of whom were on ART. Of these, 60% were virally suppressed. It found failings in a number of key stages in the HIV care journey (sometimes known as the ‘continuum of care’); namely diagnosis, linkages to care, retention in care, initiation of ART, and viral suppression. Each will need to be addressed in turn if China is to end AIDS by 2030 as it has pledged to do.

China has the resources it needs for effective HIV treatment, but it needs to create better access to these resources and to prevent new infections. Stigmatising behaviour towards key populations and a lack of sexual health education are huge barriers to a more effective response.

For this to change the general population needs to have a clear understanding of how HIV is transmitted, how to prevent it, and how treatment works as part of a public health strategy.

At the same time greater effort is needed to provide more targeted interventions that adequately support marginalised key populations. There needs to be more coordination between community level HIV organisations and national level services is if the country is to curb its HIV epidemic.