Compared to its massive overall population of 1.3 billion people, the HIV epidemic in China is still relatively tame, with an estimated 750,000 people infected. But the steady increase of the disease during the latter part of the 20th century, as well as its spread within individual high-risk groups, poses a growing threat. In 2009, 26,000 people in China reportedly died from AIDS (Note: HIV is the virus that causes AIDS). For the first time, AIDS surpassed tuberculosis as the leading cause of death among infectious diseases in China.

A couple years prior, in 2007, heterosexual intercourse overtook drugs as the main transmission method of HIV. A large portion of this sexually transmittal route is largely due to prostitution and related illegal sexual activities within China. The prostitution industry is one under general scrutiny in itself, running rampant in large coastal cities and areas of new economic development. As problems tend to breed problems of their own, discretion and corruption within prostitution circles have fueled a looming epidemic of AIDS and HIV.

To gain a fundamental understanding of the spread and potential risks of HIV among prostitutes and their clientele in urban areas, we can first examine China's historical dialogue with the disease – its quick rise within high-risk, rural areas of the country and how it quickly spread from drug users to prostitutes. Despite both being shunned by traditional Chinese societies, researchers have rarely found drug use and prostitution to have any positive correlation. Next we must explore the lack of education and social stigmas of the disease, led by a governmental ignorance and slow reaction times. Third, we should consider the effects of migration to coastal cities in the 20th century, and how the development of SEZs (Special Economic Zones) linked prostitution and disease with prosperity and opportunity.

A history of ignorance: The rise of HIV in the 80's and 90's

The first reported case of AIDS in China was documented in 1985. Because it wasn't a "problem" in China, and the Chinese were not thought to be susceptible to this disease that was brought on by the laowai (foreigners), many of the initial cases in the country focused on prevention or risks. In fact, in 1987, public authorities claimed that AIDS would not become in issue in China, as "homosexuality and abnormal sexuality were limited problems" in the country (with Chinese learning about AIDS and homosexuality at approximately the same time, the two were erroneously believed to be mutually inclusive).

AIDS was originally given the name aizibing (爱滋病) – a Chinese translation that perhaps not too coincidentally, sounds like "loving capitalism disease". Previously characterized as a "Western" problem brought in to the country by foreigners, the initial reaction to its breakout in the 80's was to mandate all foreigners to pass HIV tests if they planned to stay in China for one year or longer.

In 1989, 146 injection drug users in Yunnan province tested positive for HIV and quickly spread as a mini-epidemic among all drug users in the province. This was no longer a disease that could be blamed on the laowai. Drug use and the sharing of needles continued in rural areas, and in 1996 the Ministry of Health released a report estimating a hazy 50,000-100,000 infections of HIV. By 1998, just over a decade after the first reported case, HIV positive individuals were named in all 31 provinces, with drug users bearing the percentage of 60-70% of this infected population.

Also on the rise during this time was the spread of the disease via blood transmissions. In the 1980s, China placed a ban on imported blood products, used for blood transfusions. Ironically, what was first thought to be preventative measures actually fueled the spread of HIV within China's own borders. Blood and plasma donation centers were set up throughout China, often in rural areas where blood centers were often operated illegally and authorities were less likely to interfere. Collected blood would be pooled together and the plasma removed, then blood would be injected back into the donors to speed up recovery time. Through this method as well as the reuse of syringes and needles, hundreds of thousands of donors and recipients quickly became infected with HIV. By 2005, of those who had donated or received blood, 10% were infected with HIV.

Lack of education and social stigmas

As the number of patients with HIV/AIDS increased, the government began to realize the risks of the disease turning into a countrywide epidemic. Placement of regulations in blood banks and screening offices increased. However there was still an enormous gap to bridge in HIV/AIDS education. Though government-backed programs were established, many of the more heavily infected areas were located in rural areas. It is difficult to say how many of these programs were actually being implemented by local authorities. Moreover, a lack of qualified teachers in these areas coupled by few appropriate teaching materials made raising awareness especially difficult.

In 2008, a survey of 6,000 respondents in six large cities of China was conducted on the subject of HIV. Forty-eight percent thought that HIV could be transmitted via mosquito bites, and 18% thought that they could be infected if someone infected with HIV sneezed or coughed on them. Thirty-two percent of interviewees thought that people with HIV or AIDS deserved the disease due to inappropriate behaviors such as drug use or sexual activities. Forty-eight percent of respondents refused to eat with someone who was infected with HIV, and 30% thought that children with HIV should not attend the same schools as unaffected children.

Migration: the movement of sex and HIV

A disease that spread in rural cities of China quickly became a countrywide problem, as the migration of workers leaving rural cities for big urban areas exploded. Low rates of condom use, combined with the absence of AIDS education and healthcare have made the younger, rural-to-urban migrant worker population both the greatest sufferer and greatest threat to the spread of HIV in China.

Out of the 5,635 HIV and AIDS cases recorded in Beijing in 2008, 75.1% were reported from internal migrants, while only 21% were residents and a mere 3.9% from foreigners.

Official statistics have placed the number of migrants at over one-tenth of the country's huge 1.3 billion population. The economic boom draws rural Chinese to cities for better opportunity and more money. The lack of respectable jobs for all the young women arriving in these big cities result in many women resorting to finding work in massage parlors, karaoke bars, or dance halls. Moreover, study of the sex industry in rural China found that young women's desire to get rich, compounded with their belief to make use of their beauty before it slips away, have led many to consider working hard a waste of time, finding prostitution to be a viable and equitable alternative.

There are an estimated 10 million prostitutes in China, contributing to as much as 5% of the country's GDP. In a system that has a caste system all on its own – from low level prostitutes in roadside brothel houses to high level clubs catering to wealthy businessmen in city centers- there is a strong negative correlation between a girl's place in the prostitution tier and her risk of contracting a venereal disease. In other words, the seedier the joint, the higher the risk of HIV.

Condom usage rates hover at around 30% between prostitutes and their clients, but this always depends on the customer. A study of 350 female sex workers in Beijing reported that 76% of their clients refused to use condoms. More than two-thirds had non-paying, regular partners and only 22% had ever been tested for HIV.

In 2009, 42% of newly infected HIV patients became infected via sexual intercourse, and sex has since overtaken drug use and blood donations as the largest transmission factor of HIV. Despite these numbers, a crackdown on prostitution is not necessarily the appropriate response, and can in fact be counterproductive. In the 1990s, 700,000 sex workers and clients were arrested. Due to poor education and the fear of being imprisoned, police raids and strict legal implications have left female sex workers afraid to seek help, testing, and treatment for HIV.

A growing epidemic

The birth and quick growth of the disease in China, coupled with ignorance and stigma and migration into larger cities and its final resting place into the sex industry has created a bomb of an epidemic that is just waiting to explode. After years of denial and inaction, the Chinese government has finally realized the dangers and risks of HIV/AIDS within China, and has begun to initiate programs to help tackle the epidemic.

A study from 2010 reported an estimated 740,000 people in China who are infected with HIV. Though large enough, actual figures are likely much higher, as testing and surveillance are limited, especially in rural areas.  Many migrants and sex workers will never receive testing or diagnosis due to social and industry stigma.

China is known for rapid-fire growth in its major cities, and a tradition of strict adherence to traditional values – particularly in the face of "newfangled" problems. The hard truth, however, is that if the lack of education and perpetuated stigma of the disease persist without an understanding of its most fundamental problems, China faces a huge pending epidemic of HIV and AIDS in the 21st century. 

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Keywords: aids china HIV awareness China aids epidemic china