Waking up to AIDS

The poor but scenic Yunnan province is in the forefront of China's battle against AIDS.

PALLAVI AIYAR in Kunming

IT is a quiet morning at the Da Shu Ying Health Centre, an unobtrusive building tucked away in a warren of lower-middle class residential housing in downtown Kunming. The excited chattering of children playing at the adjoining primary school wafts into the clinic's foyer. A few staff outfitted in bright white lab coats swish around with patient files.

At around 9.30 a.m. the first patient of the day, Ou, walks in. His hair is combed back neatly and his expression is a little tense. He looks neither to the left nor to the right and heads straight for the medicine counter where he hands the two attendants a prescription. A few seconds later he is given a paper cup, the lime-green contents of which he gulps down gratefully in one swallow. His expression lightens and he exhales heavily in relief as he sits down on a nearby bench.

Ou is in fact a heroine addict. At 35, he has been using the drug for over 15 years. Having been arrested and locked up in police detoxification centres more than 10 times he had lost all hope of ever recovering. "I came close to suicide more than once. I lost my job, my wife divorced me and my mother died of grief," he recounts, his voice betraying little emotion. "I lost all decency and cheated my friends and family constantly for money," he continues.

Then around a year ago he heard of the Da Shu Ying Health Centre, one of the eight methadone treatment clinics the local government has opened in Kunming, capital of Yunnan province in southern China. Methadone is a synthesised narcotic, and at these centres it is administered to addicts orally under close medical supervision. The aim is to help heroine addicts break their habit, keep out of trouble with the law and ultimately remain protected from Acquired Immuno Deficiency Syndrome (AIDS).

Yunnan, a multi-ethnic region of stunning sub-tropical scenery is one of China's main tourist draws but it also hides a more unsavoury reality. It is the AIDS capital of the middle kingdom, being home to some 40,000 of the 140,000 Chinese who are officially known to be Human Immunodeficiency Virus (HIV) positive. Experts say that in reality there could be upwards of 200,000 HIV cases in the province and even official estimates put the figure at around 80,000.

"We have a real crisis in Yunnan. We are doing everything in our power to fight it but the AIDS situation is only growing worse," says Zhang Chang An, Director of the Office for the Prevention and Control of HIV/AIDS of the province. Zhang is unusually candid for a government official, but then, Yunnan has been at the forefront of China's fight against the disease.

While many of China's other regions spend more time pretending that AIDS does not exist rather than facing up to it, Yunnan has begun to experiment with novel pilot projects such as methadone therapy and needle exchange programmes for intravenous drug-users. The province has also welcomed support from international organisations and devotes a substantial part of its over-stretched local budget to fighting HIV.

Impoverished and underdeveloped, Yunnan shares an over-4,000-km-long porous border with the notorious golden triangle states of Laos and Myanmar. The province thus has some of the worst drug and prostitution problems in the country. Geographical proximity to drug-producing areas means that heroine is easily available in a region already experiencing wrenching social dislocation.

China is experiencing some of the fastest social and economic changes ever witnessed in history and provinces such as Yunnan have been left behind while the economic boom has brought prosperity to the country's eastern seaboard. In Yunnan poverty forces young women to sell sex.

The local government is aware that this combination of growing drug use and commercial sex is deadly and that AIDS is a potential time bomb in the region. Last year alone 8,000 new HIV cases came to light in the province and this is only the tip of the iceberg.

According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), only some 25 per cent of all HIV carriers in China have been tested for the virus, leaving 75 per cent of those infected ignorant of their status. The vast majority of HIV-positive people in Yunnan, as in the rest of the country, are thus unmonitored and unaccounted for.

China has an estimated 650,000 cases of HIV. With 70,000 new cases reported last year, some experts warn that if unchecked the number could rise to five million by 2010. "Predictions are very unreliable. The real numbers are anyone's guess because those who actually report into the system are so few," explains Ole Schack Hansen, Advocacy Adviser for UNAIDS China.

For years the Chinese government denied it had an AIDS problem at all. The first cases of HIV were discovered in the late 1980s but were portrayed as isolated occurrences brought into the country by foreigners. The general lack of awareness of the disease that this attitude led to had tragic consequences. In the early 1990s a government-organised blood-buying programme in central China's Henan province resulted in the contamination with HIV of the entire province's blood supply.

Commercial blood sellers during this period paid donors for plasma. In order to maximise profits they separated red blood cells from the plasma and then re-infused the donors with pooled red blood cells so that they could donate blood more frequently. An estimated 70,000 to 250,000 villagers in the province became infected with HIV as a consequence.

Because of the local government's involvement in this disastrous scheme, the entire incident was kept under wraps for years. Local media were banned from reporting it and activists who tried to publicise the tragedy were jailed.

But slowly information of the incident leaked out and the international and domestic uproar that followed has gone a long way in changing governmental attitudes. Thus in March 2003, China launched a programme to provide anti-retroviral drugs to all infected blood donors in Henan province. Condom advertisements, previously banned, made a debut on national television and radio. Government leaders began to be photographed visiting AIDS patients in hospitals and homes.

According to Hansen the Central government has shown an increasing commitment to fighting the disease over the last few years and efforts have stepped up, making use of the lessons learnt from the handling of the Severe Acute Respiratory Syndrome (SARS) epidemic of early 2003. At the time the Chinese authorities were shown to have deliberately under-reported infections, placing thousands of people at potential risk. But once the cover up was exposed the authorities moved swiftly; they sacked the Health Minister and ordered greater transparency in reporting infections across the board.

The SARS epidemic in fact served as a clarion call for raising awareness of infectious diseases in general, and the battle against AIDS benefited as a result. Today, over 20,000 patients with AIDS are receiving anti-retroviral drug treatment nationwide. From $12 million in 2001, the Central government budget for fighting AIDS rose to $100 million at the end of 2005.

A national programme called the "four frees and one care" is currently being promulgated. It includes free medication for rural residents and those with financial difficulties in urban areas; free voluntary counselling and testing for all; free drugs for pregnant women; and free schooling for children orphaned by the disease.

"All the right policies are now in place. The problem as usual is in the implementation," said Hansen. "The localities often interpret the Centre's directives in their own way and many of those who should be getting anti-retrovirals for free don't," he added. Nationwide only about 25 per cent of those infected with HIV are in fact receiving appropriate medication and China had 25,000 AIDS-related deaths last year.

Yunnan's authorities , however, are doing much better than most other local governments. Despite being one of China's poorest provinces, all of Yunnan's 1,600 known AIDS patients are receiving free treatment. A one-year course of anti-retroviral medication costs anywhere between RMB4,000 and RMB6,000 ($500 and$750). The per capita income in Yunnan is roughly $900.

In 2005, the province spent a total of RMB250 million ($31 million) in fighting AIDS, around half of which came from the Central government, and the remaining portion came from the provincial and local authorities. Yunnan has established 284 voluntary counselling and testing sites and all hotels and entertainment centres in the region have been ordered to make condoms available on their premises.

A 200-bed, RMB139 million ($ 17.3 million) hospital especially for the treatment of AIDS is currently under construction in a town 30 km west of Kunming. Hundreds of health workers have been trained in administering anti-retroviral medication and police officers are given training to sensitise them to the special risks faced by drug-users.

The province has also established several needle-exchange centres, where intravenous drug users can bring in used needles and exchange them for new, sterilised ones. According to Zhang the province distributed 800,000 clean needles in 2005.

Over 50 methadone clinics, with a total of 3,500 registered patients, have been opened province-wide and mobile methadone vans that will visit addicts who are unable to travel at their homes are being planned.

At the Da Shu Ying Health Centre, Li Yu, its director, revealed that 250 patients had registered since the centre opened a year ago. In addition to providing the addicts with controlled doses of methadone at highly subsidised prices (each patient pays only RMB10, or $ 1.25 a day), the clinic also promotes AIDS awareness and provides counselling services.

Zhang, however, said none of these efforts was adequate. "We need more money, more international assistance, more medicines, more of everything," he said blandly.

Dr. Wang Yu, head of the new AIDS hospital that is coming up outside Kunming, agrees that the province faces several weighty challenges.

The biggest worry, she says, is that the AIDS epidemic is no longer confined to drug-users. While over 60 per cent of the province's HIV cases are still to be found among Yunnan's 70,000 known drug offenders, the percentage of drug addicts in the total number of HIV-positive cases is falling.

Currently some 30 per cent of those with HIV in the province contracted the virus sexually. "We can say that AIDS has already entered the mainstream of society in Yunnan," Wang concludes.

This is in fact a problem across China. Nationwide only 44.4 per cent of the total HIV cases comprise intravenous drug-users. While 10.7 per cent are former commercial blood and plasma donors, almost 20 per cent comprise sex workers and their clients.

Moreover, as Grace Hafner, director of the China programme for Population Services International (PSI), a U.S.-based group that operates a counselling centre for drug users in Kunming, points out, the stigma faced by HIV-positive people remains huge. Stories abound of doctors in rural areas refusing to treat patients with AIDS. Shunned by family and friends they thus go underground rather than seek help.

Wang adds that locating and identifying people affected by HIV has in fact become more difficult following recent legislation intended to help those with the disease. Since all AIDS patients are now entitled to free medication in Yunnan province, patients have been required since 2004 to give their real names and addresses to health workers. This has however had the unintended effect of discouraging people to come forward for treatment. The stigma surrounding the disease prevents many from revealing their identity even if the alternative is certain death.

Finally, the conflicting priorities of law enforcers and health workers continue to complicate the fight against AIDS. Drugs are illegal in China and most police officers view drug-users as criminals to be cleared off the street and forcibly locked up in police-run detoxification centres. Those rounded up spend three to six months in boot-camp-like conditions but over 90 per cent of the inmates return to drugs once released. In order to qualify for treatment at a methadone centre a patient must have spent at least two spells in a detoxification centre, although the health bureau of Yunnan is trying to have this requirement rescinded.

While AIDS awareness sessions are supposed to be part of the regime at police detoxification centres, the main thrust is in fact on discipline and forcibly keeping users away from drugs. Zhou, a 50-year-old addict who started using heroine in 1988 and recently joined a methadone clinic for treatment, has spent eight spells in police detoxification centres. He now spends most afternoons at a PSI-run drop-in clinic for addicts in Kunming in the company of others like him; drug-users who are trying desperately to quit.

"I knew nothing about the connection between AIDS and drug use until I came to PSI around a year ago. I have taken drugs for more than 20 years and spent endless months in police centres but I still knew nothing until I attended some of the PSI awareness talks," he says.

Zhou lost his job as a taxi driver seven years ago and has been unemployed since. He is divorced and has not seen his son in several months. He smiles wearily: "I am lucky I didn't get sick. But not everyone is as lucky."