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A candid history uncovers China’s stumbles and successes in the fight against AIDS

HIV/AIDS in China: Beyond the Numbers

Zunyou Wu, Ed.
People’s Medical Publishing House,
2016
191 pp.

By the mid-1990s, the terror of the early AIDS epidemic had subsided in many western countries, as antiretroviral therapy transformed the once-deadly disease into a chronic condition. In China, however, the AIDS epidemic was just getting started. Slipping across the nation’s southern borders via injection drug use, the virus went largely undetected until it exploded among tens of thousands of plasma sellers in rural China. Up to that point, many Chinese leaders had naively hoped that the absence of “social evils,” such as prostitution and illegal drugs, would prevent the infection from taking root in the country. HIV/AIDS in China: Beyond the Numbers is a fascinating account of how the AIDS epidemic forced these leaders into action.

This slim volume is full of quotes from researchers, policy-makers, and clinicians who were on the front lines of the epidemic. On the first page, Zunyou Wu (director of the National Centre for AIDS/STD Control and Prevention at China’s CDC) and Elizabeth Pisani (King’s College London) state, “[E]veryone involved felt that it was important to give an honest account of these events; they all recognise that the lessons of the past have contributed in important ways to the strength and success of China’s response at present.”

As promised, the pages that follow are remarkable for their candor, detailing many shortfalls on the part of the Chinese government. A slow response to the plasma seller outbreak, for example, meant that even though the first HIV cases were detected in this group in the mid-1990s, many of the infected were still undiagnosed and untreated when the story broke in the national and international news around the year 2000.

The book also details how rank-and-file researchers and patient advocates went to heroic lengths to prevent new infections. We learn, for example, how the organizers of a national training workshop that took place early in the epidemic instructed shocked participants to head outside to practice talking to sex workers; how one deputy director at the All-China Women’s Federation took advantage of her boss’s absence to apply for HIV prevention funds from the World Bank; and how virologist Laiyi Kang narrowly escaped arrest for instituting an experiment that provided free condoms in the bathrooms of a high-end hotel in Shanghai.
The book describes how, eventually, senior leaders took notice of the successes that these AIDS pioneers had carefully documented. When the Chinese government did decide to support prevention and treatment efforts in earnest, it did so with all of its weight. The government’s spending on AIDS skyrocketed from a mere US$2 million in 2000 to $600 million in 2015. And between 2010 and 2014, health officials reduced the number of steps between HIV screening and treatment from 4 to 1, thus increasing the percentage of individuals with a confirmed HIV infection who had initiated antiretrovirals from 40% to 90%. Most recently, in February of this year, the government announced that anyone with a confirmed HIV diagnosis can seek free treatment immediately, regardless of CD4 cell count.

This account of China’s transformation from HIV laggard to leader will be valuable to other countries seeking to meet the Joint United Nations Programme on HIV/AIDS 90-90-90 target (i.e., by the year 2020, 90% of people living with HIV will know their status, 90% of people with HIV will receive sustained antiretroviral therapy, and 90% of people receiving antiretroviral therapy will achieve viral suppression). In particular, countries dependent on donor funds may want to take note of the Chinese government’s insistence on using international assistance to meet national objectives rather than donors’ objectives and on satisfying grantors’ reporting requirements with a single, centralized data platform built to meet nationalneeds  and reduce paperwork.

As the authors acknowledge, though, many features of China’s system may be difficult for other nations to replicate. Few countries have such a strong central government, and whereas today over 99% of funds for HIV programs in China come from domestic sources, many AIDS-stricken countries do not have the resources to ramp up funding in this way.

As the authors point out, it remains to be seen how China will adapt to the changing HIV landscape; to what extent its topdown government will be able to partner with grass-roots community groups to reach at-risk populations; and whether the stigma that impedes prevention and treatment efforts can be reduced. However, this book offers a vivid history of China’s response to HIV from the pathogen’s emergence until the present, and it joins the relatively thin ranks of books that offer first-person accounts of important eras in public health. This is a must-read book for anyone interested in HIV, infectious diseases more generally, or global health.

About the author

The reviewer is at Harper Health and Science Communications, LLC, Seattle, WA 98117, USA.