HIV in China: Understanding the Social Aspects of the Epidemic
By Jing Jun
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About this ebook
The result of collaboration between the University of New South Wales and the Tsinghua University in Beijing, this unique chronicle maps some of the most important social, political, and cultural characteristics of the HIV epidemic in China. Demonstrating that the epidemic was propelled by three main economic drivers—the blood trade, the drug trade, and the sex trade—this informative compilation of essays uncovers the hidden truths about the spread of HIV and analyzes its social impacts.
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HIV in China - Jing Jun
Introduction: Building HIV Social Research Capacity
Jing Jun and Heather Worth
Although China’s first case of HIV was diagnosed in 1985 and by the late 1990s hundreds of thousands of confirmed HIV infections had accumulated, social research in HIV was almost non-existent within the People’s Republic. This was partly because HIV was regarded by the Chinese community of social scientists largely as a medical problem and partly because there was little funding for social research on HIV in China before 2000. Fortunately, however, international HIV programs operating in China later welcomed the participation of social scientists. In particular, the China-UK HIV/AIDS Prevention and Care Project – launched in 2001 and completed in 2007 – encouraged a significant number of social scientists to take part in action research on HIV by performing baseline studies and program evaluations. Now, social researchers within China who have taken up HIV issues include sociologists, anthropologists, health economists, scholars of social psychology and gender studies, as well as researchers in legal studies and public administration.
To help China build greater capacity to carry out HIV social research, the University of New South Wales (UNSW) in Australia and Tsinghua University in China began to explore areas of collaboration in 2008. Subsequently, the two universities selected ten Chinese social scientists to attend a specially designed month-long HIV social research training workshop, first conducted in Beijing and then in Sydney. Aimed specifically to train younger Chinese scholars, the workshop included nine Chinese researchers in their 20s and early 30s.
The present book is one of the outcomes of the Beijing–Sydney workshop and subsequent AusAID funding through the Australian HIV Consortium; all the contributors to the nine chapters participated in the workshop. This book is an outcome of that workshop.
This book on the social aspects of China’s HIV epidemic takes the position that HIV is not purely a medical problem. In fact, while and because HIV is spread through blood, sexual fluids and breast milk, it is a disease which is laden with real and symbolic power. We believe that HIV is a social, cultural and political problem for which we jointly have to find solutions that are based in local situations. While there has been a hierarchy of research evidence which has privileged the clinical and the epidemiological over the social, since the HIV epidemic began, social research has played an important part in how we have come to understand HIV and has been central in the evidence of how to best respond in different contexts. In an interview with Mykhalovskiy and Rosengarten (2009), Susan Kippax states that without embracing social and cultural theory it is impossible to understand the social and cultural production of sexual practice and how to intervene socially to change sexual risk. The social and the cultural are critical to understanding the many different HIV epidemics throughout the world.
So, in this book the authors have emphasised the social aspects of HIV through local understandings of social settings – the environments in which HIV infection occurs and in which the impact of HIV is felt. This is reflected in the ways the authors write about the lives of those most at risk of HIV – the social and cultural contexts in which they come to be affected by and infected with HIV, how they are treated in their communities and by authorities, health systems and the media.
Jing Jun at Tsinghua University and Heather Worth at UNSW wrote the book’s first chapter, which serves as an overview of China’s HIV epidemic and emphasises the function of inequality in the epidemic’s outcomes. Jing Jun and Heather Worth argue that China’s HIV epidemic – until recently – closely followed two socioeconomic paths. On the one hand, the epidemic was propelled by three economic drivers: the blood trade, the drug trade and the sex trade. On the other hand, the epidemic progressed at the cost of three socially marginalised populations: impoverished rural residents in central China, ethnic minorities in border regions, and female migrant workers in many Chinese cities. Recent discoveries of an alarmingly high HIV prevalence among Chinese male homosexuals have added greater complexities to the country’s HIV epidemic.
Chapter 2 by Huang Yingying deals with the Chinese sex industry. Huang argues that the Chinese strategy for HIV prevention suffers from a narrowly defined concept of risk and operates at the cost of ignoring a complex set of other concerns among female sex workers. She contends, for example, that the public health sector’s effort to promote condom use among sex workers, and especially among ‘hair-salon girls’ who are positioned at the lower end of the sex industry, often fails to consider their fears of violence, pregnancy, infertility and identity exposure. This failure remains an obstacle to the country’s prevention of sexually transmitted infections (STIs) and HIV via the sex industry.
In chapter 3 Jing Jun explores heroin use among Chinese youngsters. As heroin injecting has constituted a major propeller of China’s HIV epidemic, Jing Jun argues that heroin consumption among Chinese youngsters usually follows certain youthful behaviour, such as smoking, drinking, truancy, multiple sexual relationships, overnighting in internet bars, stealing and gang fighting. As a prelude to injecting drug use, these behaviours are characteristic of a subculture formed through intimate relationships among youngsters who share similar experiences of academic failures in an extremely competitive education system; a string of troubles with authorities, and a need to carve out an identity for themselves.
Su Chunyan, in chapter 4, addresses the question of how plasmapheresis – a biomedical technology to collect and extract plasma from blood – played a devastating role in the spread of HIV in central China in the late 1990s and early 2000s. Adopted for use in a market of blood sales during the early 1990s, this machinery was used in hazardous ways and led to HIV infections among rural residents who were trying to make an extra income out of paid plasma donations. Su Chunyan argues that the technical risks inherent in the use of plasmapheresis were amplified by social risks. These included a market situation in which trade in blood and plasma was widespread, a political environment in which the careers of government officials depended on local GDP achievements, and a social climate in which attitudes towards selling blood among rural populations changed from something shameful to a way to afford consumer goods.
Zhang Yuping tackles the sensitive issue of Chinese gay men living with HIV and how they perceive the importance of confidentiality in chapter 5. Among these men confidentiality is the top concern. Their constant fear is a double exposure: that both their HIV status and gay identity could be exposed by medical providers or social agencies. Once exposed, they fear rejection by the gay community because they have HIV, and by society at large because they are gay. This fear is well founded, Zhang Yuping explains, since breaches of confidentiality with regard to people living HIV are a serious problem in China. Her study was conducted in the city of Chengdu where she collaborated with a local gay organisation in applied research in response to a sharp increase of HIV infections among local gay men.
In chapter 6 Sun Yongli explores condom use and HIV disclosure after individuals have tested HIV positive. There has been a prevailing belief in the Chinese medical community and news media that deliberate deception and irresponsibility on the part of those living with HIV account for much of the year-to-year increase in the newly discovered HIV infections in China. Her study of 131 respondents in a city in southwestern China shows that barriers to HIV disclosure and condom use involve a ‘principle of psycho-social distance’ that defines a complex set of human relationships. She therefore argues that changes in sexual behaviour should not be expected to be a natural outcome of a sero-positive diagnosis. Nor should failures to engage in HIV disclosure be assumed as a matter of deliberate deception or irresponsibility. The deciding factors for safe sex and disclosure to happen, she says, are the contextualised social relations in which the HIV-positive individuals find themselves.
In chapter 7, He Mingjie discusses the centrality of the family in Chinese society. By analysing 71 narratives collected via an oral history project, her study shows that the Chinese family can be a source of tenderness and care in most circumstances, including its encounter with HIV. But it can also be a source of great affliction. She contends that familial relations constitute a wide range of multifaceted dynamics that directly affect the quality of life among the people infected with HIV. Her study demonstrates that HIV-related stigma is not only widespread in society in general but also penetrates into the social fabric of a basic source of human intimacy in Chinese society – the family.
In chapter 8, Zhang Youchun argues that the source of HIV-related stigma and discrimination in China can be traced to ideas and metaphors associated with the attitudes of government agencies, news media and health professionals. He suggests that stigma itself is a powerful driver of the country’s HIV epidemic because discrimination via denial of employment, residence, education and welfare, as well as personal fear of isolation, ridicule and helplessness, interact with one another and develop into a formidable force of deterrence of safe sex or drug use, disclosure of status and HIV testing. Because of stigma, at-risk individuals are afraid of HIV testing, while those already living with HIV are afraid to inform their intimate partners of their status.
Written by Huan Jianli, the book’s concluding chapter is concerned with how Chinese social scientists have dealt with issues of inequality in relation to ethnic minorities and migrant women. His chapter indicates that social research on HIV in China remains a highly sensitive endeavour, as it leads to uncomfortable questions for people in power. In addition, some social research findings have the potential to be sensationalised by the news media. Chinese social scientists therefore have had to carefully maintain a fine balance between HIV research and politics, between objectivity and advocacy, and between the necessity to create social awareness through applied research and the need to avoid stigmatising social groups that are already faced with many forms of discrimination.
At the end of our preparation of this manuscript, UNSW and Tsinghua University collaborated once again by organising another training workshop for Chinese social scientists. This time, the workshop drew 20 young scholars from Yunnan, Guangxi and Sichuan, once more with the goal of publishing research from young scholars. We are extremely grateful that the collaboration between the University of New South Wales and Tsinghua University has been moving ahead smoothly. We share the belief that Chinese social scientists are central to the evidence-gathering that has contributed to and will continue to help advance China’s HIV prevention.
References
Mykhalovskiy, Eric & Rosengarten, Marsha (2009), ‘Commentaries on the nature of social and cultural research: interviews on HIV/AIDS with Judy Auerbach, Susan Kippax, Steven Epstein, Didier Fassin, Barry Adam and Denis Altman.’ Social Theory & Health Vol 7/3, co-edited and introduced by Eric Mykhalovskiy & Marsha Rosengarten.
1
An Overview of China’s HIV Epidemic
Jing Jun and Heather Worth
The first case of HIV in China was discovered in 1985. By the end of 2007, the Chinese government had declared that China had a total of 223,501 confirmed HIV cases, although it estimated that 700,000 people were living with HIV in China at this date. This estimate was calculated on the basis of HIV prevalence among five populations at risk: injecting drug users; female sex workers; clients of sex workers; those with sexually transmitted infections (STIs), and paid blood donors (Jing, 2005). By the end of 2009 this total had risen to 740,000. Considering that China has a population of one billion, its HIV prevalence epidemic is low, but complacency could quickly accelerate the epidemic.
This chapter will discuss the unfolding of the HIV epidemic in China. At the outset, we want to note that an energetic response to HIV was lacking in China until late 2003.¹ The turnaround in China’s HIV response was due to the combination of two events. First, a new generation of leaders in the Chinese Communist Party and the Chinese central government came to power during the Severe Acute Respiratory Syndrome (SARS) crisis of 2003. Second, the SARS epidemic made these new leaders keenly aware of how a small virus could trigger widespread panic, first in China and then throughout the world.
We also want to state that HIV is not indiscriminate in its choice of victim, and this applies to China as well. The routes for HIV transmission are behaviourally based, but there is a definite socioeconomic gradient in the ways in which it affects people. The behaviours rendering certain populations susceptible to HIV very much hinge on that population’s social standing, economic status and everyday experiences of struggling against various adversities. As the following analysis makes clear, the majority of those who have borne the brunt of the HIV epidemic in China live at the bottom of Chinese society. In attempting to improve their lives, they share numerous risks in three markets: the blood trade, the drug trade and the sex trade. These three markets have served as the main drivers of China’s HIV epidemic.
The blood trade
Of China’s official tally of confirmed HIV cases accumulated from 1984 to 2007, 23.6 per cent can be traced to the trade in blood and blood transfusions. The huge impact of blood sales in China until recent years underscores the fact that China’s HIV epidemic is unique because of that trade. Trade in human blood began in China after the technology of blood transfusion was introduced by missionary hospitals in major Chinese cities at the turn of the twentieth century. In the first half of that century, voluntary donations of blood were limited to wartime situations when army generals called upon soldiers and citizens to give blood for the wounded. With the founding of the People’s Republic in 1949, China’s blood supply was dominated by remunerated sources, supplemented by compulsory donations. Even at the height of socialism under Mao Zedong from the 1950s to the 1970s, an underground