IV. Background

HIV/AIDS in China

As of 2007 there were approximately 700,000 people in China living with HIV/AIDS.[1]   Heterosexual sex and injection drug use are the main modes of infection, with each thought to account for about 40 percent of transmission.[2] UNAIDS and the Chinese government reported that there were an estimated 260,000 drug users living with HIV/AIDS in 2007, and over 20,000 new HIV cases among drug users that year.[3]

The government of China's response to the HIV/AIDS epidemic has been characterized as belated but "bold."[4] In the past few years the Chinese government has announced dramatic programs to address drug addiction and HIV, including the expansion of methadone maintenance therapy and needle exchange and commitments to expand HIV prevention education targeting drug users.[5]In addition, China's 1998-2010 "Strategic Plan for HIV/AIDS Prevention and Control" included a specific goal to provide, by 2002, "health education on preventing HIV/AIDS and sexually transmitted diseases at all detoxification centers and re-education centers as well as in 80 percent of jails."[6] The government has dedicated increasing resources, supplemented by international funding, toward these goals.[7]

The Chinese government has also sought to ensure that its national policies and strategic plans are implemented locally and that the rights of people living with HIV are respected. In 2006 the State Council issued "Regulations on AIDS Prevention and Treatment" that provide a legal framework for holding different levels of Chinese government accountable in the response to AIDS and set forth the rights of those infected.[8]  The State Council also issued China's Action Plan for Reducing and Preventing the Spread of HIV/AIDS (2006-2010), which sets out to strengthen multi-sector cooperation, broaden implementation of HIV/AIDS policies, and initiate intervention for high-risk groups.

However, at the same time the Chinese government has pledged resources and support for prevention and treatment of HIV/AIDS, it has also routinely detained and harassed AIDS activists and NGOs seeking to provide direct support to people living with HIV/AIDS or conduct advocacy on their behalf.  The government has made it almost impossible for truly independent NGOs, including but not limited to those focused upon HIV/AIDS, to achieve legal standing by requiring NGOs to partner with a government agency.[9] Small grassroots NGOs have nonetheless cropped up and tried to work around these government restrictions by keeping a low profile and providing resources and services to people on a very local level. Local governments have responded by threatening and arresting staff members of these organizations, as well as people within the target community.[10]

In addition to preventing NGOs from reaching populations in need, the Chinese government has persecuted individuals who are working toward protecting and promoting the rights of people living with HIV/AIDS and their families. The most publicized case of government crackdown on citizens trying to advocate for people affected by HIV/AIDS is that of the human rights and AIDS activist Hu Jia, who has been either under house arrest or in detention for most of the last two years.  Most recently, in December 2007, after months of house arrest, he was imprisoned, and then in April 2008, sentenced to three-and-a-half years in prison for "inciting subversion against the state".[11] On October 23, 2008, the European Parliament awarded Hu Jia its 2008 Sakharov Prize for Freedom of Thought.[12] Hu Jia's wife, Zeng Jinyang, also an AIDS activist, remains under house arrest with their baby.

While the case of Hu Jia is the most prominent, and has garnered the most international interest, AIDS activists throughout China have been arbitrarily arrested and detained, or otherwise intimidated, to force them to stop working or speaking out about the AIDS epidemic and the Chinese government's response. Globally, NGOs have an established role in national and international responses to AIDS, and are recognized as critically important to expanding universal access to prevention and treatment services to marginalized populations, and for ensuring government accountability.[13] Although the Chinese government has taken steps to improve policies and expand services for people affected by HIV/AIDS, the perpetuation of an environment of fear and intimidation against independent NGOs in China has impeded the delivery of effective programs.

Conflicting Government Responses to HIV and Drug Use

As evidence of its increasingly pragmatic approach to addressing AIDS, the Chinese government, by the end of 2007, had established 503 methadone clinics in China with the capacity to serve 100,000 drug users.[14] Similarly, needle and syringe exchange programs have been scaled-up following the State Council's 2004 "Notice on Strengthening HIV/AIDS Prevention and Control," which announced that "health departments are required to cooperate with bureaus of Public Security and Food and Drug Administration to conduct pilot programs on AIDS treatment and drug adherence, needle and syringe exchange, and social marketing of condoms in areas with high HIV prevalence among injection drug users."[15]Peer education projects, often started in conjunction with needle exchange sites, have also proliferated.

Despite these positive steps, however, the Chinese government, via the Ministry of Public Security, continues to implement repressive drug policies that undermine the effectiveness of these new health-based interventions. The Ministry of Public Security, which is responsible for anti-drug squads, and which manages the country's network of compulsory detoxification centers, and the Ministry of Justice, which oversees the county's network of re-education through labor (RTL) centers, pursue policies that drive drug users away from effective prevention and treatment programs.

While general policies, including sentencing guidelines for drug users and officially sanctioned prevention activities, are set on the national level, implementation varies widely between provinces.  The national government organizes formal drug campaigns, but provincial and local officials have significant leeway in implementing activities and can promulgate supplemental laws according to their own needs.[16]For example, in some provinces needle exchange programs have been operating for several years while in others no pilot projects exist.[17]  Factors influencing local response include the availability of local, national, and foreign funding for treatment-related activities, the severity of drug use and HIV epidemics in the area, and the attitudes of local and provincial authorities.

The tension between strengthened law enforcement and evidence-based public health approaches to drug dependency has been evident even in the statements of high-level government officials. In June 2004, Chinese Premier Wen Jiabao visited a drug detoxification center and said that drug users "have violated the law, but they are victims themselves."[18]By contrast, just a year later, State Council Member and Minister of Public Security Zhou Yongkang announced a new "national people's war on illicit drugs," with a major goal of increasing the number of people sent to mandatory drug detoxification and re-education through labor centers.[19]

Even prior to the 2005 "war" on drugs, mandatory drug detoxification was by far the most common form of institutional "treatment" for drug use in China.[20]  Between 1995 and 2000, China quadrupled its capacity to provide compulsory detoxification.[21] The most recently available data from 2005 indicate that there were approximately 700 mandatory drug detoxification centers in China and 165 re-education through labor centers housing a total of more than 350,000 drug users.[22]

In 2007 the Standing Committee of the National People's Congress passed a new drug law, which went into effect in June 2008, which substantially restructures the detention system for individuals detained for administrative drug offenses, but has significant ambiguities and uncertainties regarding implementation.[23] While eliminating the use of RTL centers for the detention of drug users, the law allows up to 6 years of confinement for a single drug offense, with 1 to 3 years in 'compulsory isolation detoxification' (qiangzhi geli jiedusuo), followed by up to three years of 'community rehabilitation'. Under the new law, the local head of the detoxification center determines the specific length of sentence based upon a 'diagnostic evaluation' of the detainee. A second evaluation at the end of this period determines the length of time a detainee must spend in community rehabilitation. "Pilot" community rehabilitation sites have been recently developed on the same sites as RTL and detoxification centers in response to the legislation and appear to be run with few differences from RTL or detox, but promise to provide detainees with paid work and greater opportunities to visit and live with family (including spouses and children).[24] The legislation also increased police authority to conduct drug searches and a new anti-narcotics campaign initiated in 2007, entitled "Wind and Thunder Sweeping Narcotics," provides monetary incentives to citizens to report drug use by neighbors, relatives, and community members.[25]

HIV and Drug Use in Guangxi Province

The Guangxi Zhuang Autonomous Region is situated in southern China and has a population of 49 million people.  Bordering on Vietnam and China's Yunnan province, Guangxi is a hotspot for illicit drugs and has a high rate of injection drug use.

Guangxi has the third highest rate of HIV/AIDS in China.  An estimated 92 percent of all HIV infections in Guangxi can be attributed to injection drug use.  Officially Guangxi has approximately 30,000 people who are HIV positive, but local sources believe the number is closer to 120,000.

The Chinese Center for Disease Control and Prevention (CDC) operates 22 HIV/AIDS testing and treatment sites in Guangxi. None of the testing sites are anonymous or confidential, none have rapid HIV tests, and very few offer any kind of counseling.  As elsewhere in China, despite advertisements announcing that tests are free, they are not free in practice.  In addition to paying for viral load testing and other tests, patients also must pay all their expenses for opportunistic infections, which can range from 10 to 10,000 yuan (US$1.20 – US$1,200).

The capital of Guangxi province is Nanning, a city of just over one million urban residents. There are two detox centers housing an estimated 1,000 drug users annually, and three RTL centers (one for women, one exclusively for drug users, and one housing a mix of drug- and non-drug related residents) serving an estimated 3,000 drug users, including people coming from other cities. Voluntary drug treatment facilities support approximately 150 people per year, and as of 2005 a methadone maintenance program was treating approximately 130 people.

Despite having only 5,000 registered drug users, it is estimated that there are 70,000 injection drug users (IDUs) in Nanning. A local NGO estimated that, as of 2007, 15,000 people in Nanning had tested HIV positive, but only 2,000 were receiving any treatment. Organizations providing health care to IDUs in Nanning said that, as a result of obstacles in accessing treatment, approximately three-fourths of individuals present with advanced AIDS symptoms when they come to the clinic for the first time.

Baise is a small city northwest of Nanning with a population of 325,000.  In 2004 there were 466 registered drug users, although local NGOs estimate that the real number is much higher. There were 84 new HIV infections reported in 2004, 74 percent of which were believed to be related to injection drug use. Local government officials estimated that two-thirds of drug users were HIV positive. Baise has one detox center and detainees sent to RTL centers go to one of the centers in the Nanning area. Because of a large international NGO presence in Baise that specifically supports harm reduction measures, an increasing number of methadone centers and needle exchange have been established. NGOs providing HIV testing refer patients to methadone centers and offer psychological support services to IDUs coping with both addiction and HIV infection.