China faces what could become the largest AIDS epidemic in the world. Official estimates say that 840,000 Chinese men, women and children are now living with HIV/AIDS.11 However, the actual numbers are almost certainly much higher: estimates by some international experts have ranged in the millions.12 International and official Chinese experts all say that China will likely have ten million people living with HIV/AIDS by the year 2010.13
In the past two years, senior Chinese officials have begun to confront the grave threat posed to China by the AIDS epidemic and have taken steps to combat it. These steps have included the establishment of a high-level State Council AIDS Working Committee, headed by Vice-premier and Minister of Health Wu Yi, and the launching of an ambitious nationwide treatment and care program.14 The Four Free and One Care policy promises to:
In addition, some Chinese ministries have initiated new policies to inform people about HIV/AIDS and to promote the use of condoms.16 In August 2004, China amended its national law on prevention and control of infectious diseases to explicitly prohibit discrimination against people with HIV/AIDS.17 In addition, though injection drug users are still subject to arbitrary detention, China has also begun to expand more progressive methadone treatment programs. In 2004, Chinas premier Wen Jiabao called fighting the AIDS epidemic Chinas top priority.18 After many years of government denial about the epidemic, these are significant steps forward that represent real progress.
Senior Chinese officials have shown a growing awareness about the need to mobilize civil society in order to combat a range of social problems, including environmental degradation and AIDS.19 In response, Chinas NGO sector, virtually nonexistent a decade ago, has been allowed to emerge. But as this report shows, the Chinese state remains deeply ambivalent about NGOs. Chinas continuing restrictions on civil society, free expression and free association; the general lack of accountability for government officials; and the states sporadic harassment and detention of activists whose public criticism threatens the interest of some segments of the government; all combine to severely constrain the growth of a civil society that can effectively join the fight against AIDS.
There are three broad political and social trends driving the current situation: tensions between growing tolerance of NGO activism by senior officials and the more repressive views of local officials; the growing gap between coastal cities and inland rural regions; and the states harassment, censorship and detention of those most vulnerable to HIV/AIDS.
First, calls for tolerance of NGOs by senior officials exist in continual tension with the Chinese governments chronic institutional discomfort with any initiative not sponsored by the state. This discomfort leads state actors to place numerous obstacles in the path to development of independent nongovernmental organizations and websites.
In the past two years, senior national officials have shown concern about AIDS and tolerance of AIDS activism: Chinas premier, Wen Jiabao, and the vice premier and director of the Ministry of Health, Wu Yi, together visited people living with HIV/AIDS in Beijings Ditan hospital on World AIDS Day in December 2003; afterward, Minister Wu Yi had a private meeting with internationally-renowned Henan AIDS doctor and activist Gao Yaojie.20 Minister Wu has also made public statements underscoring the importance of creating an environment that will facilitate mobilizing civil society.21 Chinese AIDS activists report that they feel they now have more space to work than they had even a year or two ago. This was evident at the Fifteenth International AIDS Conference in Bangkok in July 2004, where the Chinese governments team of official spokespeople was matched, and sometimes overmatched, by an outspoken group of twenty grassroots NGO representatives.
However, signals of tolerance by Beijing are contradicted in practice by the states frequent repression of free expression and association rights, and by highly restrictive regulations, written in an earlier era, that continue to constrain the work of grassroots organizations. Statements by senior officials are also frequently in clear tension with the actions of the local officials charged with actually implementing AIDS policies, some of whom see grass-roots activism as a threat to their political control. As UNAIDS and the State Council itself jointly acknowledge, the core challenge remains that of achieving the effective implementation of these policies at the local level.22 While statements by senior officials have offered hope and encouragement to many frontline AIDS activists, they have done little to loosen the bonds in which many do their day-to-day work.
A second continuing problem is that some of the tension between local and central government authorities arises from the growing economic gulf between Chinas coastal cities and inland towns and villages. Chinas cities are developing with lightning speed, especially in coastal areas, while inland provinces and rural areas continue to struggle economically. Most of the new AIDS groups are in more developed and consequently more open cities, such as Shanghai and Beijing. But Chinas AIDS epidemic is not predominantly an urban one; it mostly affects the rural poor and injection drug users and sex workers in underdeveloped inland regions such as Yunnan, Inner Mongolia, and Xinjiang Uighur Autonomous Region.
The greatest need for social mobilization is in those areas, but those are also areas with the greatest political restraint. AIDS activists in the inland provinces face almost insurmountable difficulties in registering, fundraising, and in relations with the media. In rural areas in particular, the old Chinese saying, tiangao diyuan (Heaven is high, and the emperor is far away) often continues to be operative: activists report that national policies on AIDS are unevenly implemented, thanks to entrenched local officials who may have a limited understanding of AIDS and how it is transmitted, who see HIV/AIDS as a sign of moral corruption as well as a health disaster, and who see any public discussion of AIDS as a source of embarrassment that threatens external investment in their impoverished regions.
In some rural areas, public criticism of government authority is treated as a direct political challenge that must be quickly and firmly suppressed; some inland activists have even fled to avoid arrest. This problem is most acute in Henan province, one of the epicenters of the epidemic, and a province with a long and brutal track record of repressing AIDS activism. Henans vocal AIDS activists and the provinces proximity to Beijing have ensured it national and international attention more than other, quieterand perhaps more successfully repressiveprovinces.
The third reason why AIDS organizations and activists face ongoing problems in China has to do with the social marginalization of the people they work with. Those most vulnerable to HIV transmission, namely injection drug users, sex workers, and men who have sex with men, suffer from profound stigma, and in the case of drug users and sex workers, from draconian laws that promote arbitrary detention by police without trial. As a result, activists who work with those persons face a range of risks and hurdles. Government moral rhetoric about the importance of building a socialist spiritual civilization, a rhetoric that implicitly blames both Western corruption and persons most vulnerable to HIV for selfish personal choices that spread the virus in society, has only further marginalized and stigmatized people who most need government information and support. Official crackdowns on drug users and sex workers and censorship of frank on-line discussions of sex between men who have sex with men, have all closed the space for sharing information and mobilizing marginalized communities, and have limited the activities of activists who aim to inform them.
In response, many activists who work on AIDS, while they report greater freedom than before, continue to live in an atmosphere fraught with anxiety.23 They engage in constant checking of the political barometer, debating each other and questioning themselves about how far they can go without triggering a government crackdown. Some AIDS activists interviewed by Human Rights Watch reported that they have developed strategies to manage the political risk that surrounds their emerging field. We havent encountered any restrictions on our work, said the founder of a new group that provides AIDS information to sex workers. However, we just got started. We just keep it a little quiet, a little underground we dont do anything too loudly.24
Others report that they have learned to engage in self-censorship on certain topics. For instance, many Chinese AIDS activists report harassment by police, but are reluctant to have Human Rights Watch publish this information, even anonymously, for fear of reprisals. As one activist explained,
You can criticize the central government, but its different if you offend the local authorities, or some local interest group within the central government. Then you will be in very specific trouble I am conservative when it comes to talking about the police.25
Other first-hand accounts provided to Human Rights Watch reveal harassment of AIDS training workshops and detention of individual activists, harassment and detention of marginalized population groups that are most at risk of contracting HIV, and general bureaucratic restrictions on the activity of civil society and websites that curtail the ability of those at risk of HIV transmission to share vital information.
In 1996, the U.N. High Commissioner for Human Rights (UNHCHR) and UNAIDS issued the HIV/AIDS and Human Rights International Guidelines, explicitly recognizing the contribution of NGOs toward combating AIDS, and recommending that states ensure, through political and financial support, that community consultation occurs in all phases of HIV/AIDS policy design, program implementation and evaluation, and that community organizations are enabled to carry out their activities, including in the field of ethics, law and human rights, effectively.26
The Chinese government does work with UNAIDS and the UNHCHR. UNAIDS has an office in Beijing and cooperated with senior-level Chinese officials on its 2004 assessment of the AIDS epidemic. In 2000, China signed a Memorandum of Understanding with the UNHCHR in which both parties agreed to undertake a technical assistance program which included workshops on the punishment of minor crimes, human rights education, and Chinas police.27
The U.N. Guidelines are not binding law, but China is bound to uphold the International Covenant on Economic, Social and Cultural Rights (ICESCR), which commits China to the progressive realization of the right to health. Interpreting the right to health, the Committee on Economic, Social and Cultural Rights calls the right to health:
An inclusive right extending not only to timely and appropriate health care but also to the underlying determinants of health, such as access to health-related education and information, including on sexual and reproductive health. A further important aspect is the participation of the population in all health-related decision-making at the community, national and international levels.28
The Chinese government has taken a few steps forward in enlisting the help of an emerging civil society in the fight against AIDS, but as this report concludes, there is much yet that needs to be done, and international agencies working on AIDS in China should assist in the effort. As a member of the Information Clearinghouse for Chinese Gays and Lesbians observed,
The government should recognize that grass-roots organizations can be its right hand and can be its partners. It should recognize that NGOs are nongovernmental organizations, not anti-government organizations.29
Human Rights Watch conducted field research for this report in mainland China for a month in 2004. A Human Rights Watch researcher interviewed representatives of about a dozen NGOs and grass-roots organizations. Additional interviews were conducted via electronic mail and telephone. Information was also gathered from published reports, published Chinese laws, policies and regulations, academic articles, news reports, and library archives.
The scope of this study is necessarily limited by the constraints imposed on human rights research in China. China is increasingly open to international NGOs working on AIDS, but it remains closed to international human rights NGOs. Chinese activists, lawyers and scholars who speak to or have contact with international human rights groups risk government retaliation. Chinese scholars and activists who travel abroad are often questioned by police on their return.
Human Rights Watch took precautions to protect the identities of witnesses and colleagues who assisted with or spoke to researchers for this report. Interviews were conducted in settings that were as private as possible. All interviews were conducted in Mandarin. In addition, the names of all interviewees have been changed in this report. Identifying characteristics of interviewees have been omitted or altered, as have precise dates and locations of field research. Human Rights Watch looks forward to the day when international human rights groups can work openly with all our colleagues in China.
Because of the security concerns, Human Rights Watch researchers did not request interviews with government officials while in China, but did write to Chinese government representatives in China and in Washington, D.C., to request interviews, but received no response.
 State Council Working Committee on HIV/AIDS and U.N. Theme Group on AIDS in China: A Joint Assessment of HIV/AIDS Prevention, Treatment and Care in China (2004) (Beijing, December 2004).
 Until 2002, China claimed that only a few thousand of its citizens were living with HIV/AIDS. In 2002, the government increased the estimate to one million. In its 2002 report, UNAIDS estimated up to 1.5 million Chinese people were living with HIV/AIDS. However, in 2003, a few months before announcing plans to offer free antiretroviral treatment, the Chinese government scaled down its estimate to only 840,000 people living with HIV/AIDS, and UNAIDS subsequently endorsed that estimate in the joint report cited above. However, international estimates have been much higher. Chinas surveillance system has been criticized by many, including Chinese central authorities and the U.N. (see Joint China CDC-U.S. CDC HIV Surveillance Assessment (Beijing, China and Atlanta, U.S.A., 2002, p.1-2). Doctors and activists in Henan province still estimate that one million people may be HIV-positive in that province alone. Other international experts have expressed skepticism about Chinas official numbers; some suggest there may be between six and ten million (Anthony Saich, The Potential of the HIV/AIDS Epidemic, from Social Trends in China: Implications for the PLA, in D. Finkelstein, ed., Swimming in a New Sea: Civil-Military Relations in China, forthcoming; E-mail message from Joanne Csete, executive director of Canadian HIV/AIDS Legal Network, to Human Rights Watch.
 National Intelligence Council, The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China (Washington, D.C., September 2002) [online], http://www.cia.gov/nic/PDF_GIF_otherprod/HIVAIDS/ICA_HIVAIDS20092302.pdf (retrieved May 21, 2005); Premier Wen spearheads crusade to dispel discrimination against AIDS victims, Peoples Daily, December 2, 2003; translated by China AIDS Info [online], http://www.china-aids.org/english/News/News261.htm (retrieved May 21, 2005).
 State Council and U.N. Theme Group on HIV/AIDS in China, A Joint Assessment of HIV/AIDS.
 State Council and UNAIDS, Joint Assessment of HIV/AIDS, p. 9. In this report, the word children refers to anyone under the age of eighteen. The U.N. Convention on the Rights of the Child, ratified by China on April 1, 1992, defines a child as every human being below the age of eighteen years unless, under the law applicable to the child, majority is attained earlier (Article 1). U.N. Convention on the Rights of the Child, G.A. res. 44/25, annex 44 U.N. GAOR Supp. (No. 49) at 167, U.N. Doc. A/4/49 (1989).
 Joint Assessment, p. ii.
 Joint Assessment, p. 12. However, the law does not supercede local regulations. Explicitly discriminatory local regulations remain in effect in many provinces and cities around the country, and despite the national law, some regions have continued to enact new regulations that mandate discrimination.
 Fight against AIDS must be Chinas top priority: PM, Agence France-Presse, July 10, 2004.
 NGOs to play important role in China's AIDS prevention, control, Xinhua, April 13, 2004 [online], http://www.china-aids.org/english/News/News341.htm (retrieved May 21, 2005).
 Joint Assessment, p. 9.
 Joint Assessment, p. 13.
 Joint Assessment, p. iii.
 One notable exception to the rule that AIDS activists in urban areas are relatively free is that of Hu Jia, a prominent Beijing AIDS activist and former director of Aizhixing. Since 2003, Hu Jia has been repeatedly placed under house arrest, largely because of his activism on accountability for the June 4, 1989 massacre, forced evictions, and other issues. In late April 2005, Hu Jia was beaten by Beijing police and was detained for a week before being released without formal charges.
 Human Rights Watch interview with Hua, gay rights activist, 2004.
 Human Rights Watch interview with Su, Chinese AIDS activist, 2005.
 Office of the High Commissioner on Human Rights (OHCHR) and the Joint United Nations Programme on HIV/AIDS, HIV/AIDS and Human Rights International Guidelines (from the second international consultation on HIV/AIDS and human rights, 23-25 September 1996, Geneva), U.N. Doc. HR/PUB/98/1, Geneva, 1998, Guideline 2.
 OHCHR, Technical Cooperation Between the Office of the United Nations High Commissioner for Human Rights and the Peoples Republic of China: Information note (Geneva, September 2000).
 U.N. Committee on Economic, Social and Cultural Rights, General Comment 14, The right to the highest attainable standard of health, U.N. Doc. E/C.12/2000/04 (2000); Section I paragraph 11.
 Chen Wenjun, Shilun Zhongguo aizibing fangzhi NGOde zhunru ji guanlide falu wenti [An exploration of legal questions in the registration and management of Chinese AIDS prevention NGOs], published by the Information Clearinghouse for Chinese Gays and Lesbians, page 5; paper on file at Human Rights Watch.