September/October 2005 — #93 G L O B A L Injecting and Infecting; Stigma and Zero Tolerance in China . . . . . Page 8 ® AIDSLink Global Building Healthy Bridges in India . . . . . . . . . . . . . . . . . Page 12 Health Watching from the Shore . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 15 Council PUBLISHED BY THE GLOBAL HEALTH COUNCIL The Second Wave of HIV/AIS COUNTRIES IN ITS PATH Injecting and Infecting Stigma and Zero Tolerance Fuel the HIV/AIDS Epidemic among Intravenous Drug Users in Southwest China BY ANDREW THOMPSON, ASSISTANT DIRECTOR FREEMAN CHAIR IN CHINA STUDIES CENTER FOR STRATEGIC AND INTERNATIONAL STUDIES FOLLOWING YEARS OF DENIAL AND COVER-UP the Chinese gov- ernment has more earnestly and openly committed itself to tackling the HIV/AIDS epidemic. Still, it continues to spread, especially among intra- Top: Poster on the wall of a methadone clinic in Sichuan venous drug users in southwestern provinces. Fueled by ignorance, poverty, Province. Above: An outreach worker at an urban drop-in cheap and available heroin, needle-sharing and unprotected sex, the epi- center destroys used needles. All photos by Drew Thompson demic is having a devastating impact on communities, particularly women who are becoming infected in growing numbers and bearing the burden in affected families. Moreover, stigma and discrimination are widespread, 8 — Global AIDSLink Anti-drug and AIDS awareness slogans painted on village wall ( characters on top are in Yi, characters on the bottom are in Chinese). hampering efforts to stop the epidemic especially among marginalized groups detained at least once and many, numerous times, they have an extremely such as drug users and sex workers. difficult time re-integrating into society and frequently cannot find work because of their criminal records. Commercial sex work and drug dealing are China’s first indigenous HIV/AIDS cases emerged in the late 1980s in the frequently the only recourse addicts have to support their families and their southwestern province of Yunnan, in counties bordering Myanmar (Burma), habits. where most of the heroin entering China is produced. Since then, HIV has steadily spread along drug trafficking routes to interior and coastal provinces. Unable to find legitimate work and without access to psychosocial support, Today, health authorities in each of China’s 31 provinces report HIV-epi- those who try to break their addiction frequently face bleak prospects. demics among injecting drug users. Nationwide, more than 100,000 HIV Because of intolerant policies and practices, drug abusers fear interacting with cases have been identified and registered with health authorities since 1989, authorities of any stripe, including health services. Programs seeking to dis- with half of those infections attributed to sharing syringes. Currently, the tribute clean needles are unable to adequately outreach into drug-using com- ministry of health estimates the current number of HIV cases alive today at munities, both because of community rejection and a lack of support from 840,000. The enormous divide between identified and estimated cases indi- the police, increasing the likelihood that users will share equipment. cates that surveillance systems are woefully inadequate. This knowledge gap Additionally, many communities are intolerant of drug users as well as sex presents a particular challenge to public health authorities seeking to track workers, creating barriers to HIV-focused programs seeking to establish the expanding epidemic, decreasing their ability to effectively allocate effective interventions. Sex workers in particular, some of whom are also resources where incidence is growing most rapidly, such as among the drug drug users, are highly mobile and rarely engage clients close to home, posing using population. an additional challenge to public health authorities who are unable to build durable relationships with those most as risk. These dynamics contributes to In 2004, public security authorities had cumulatively registered 1,140,000 society’s view of drug users and sex workers as “outsiders,” a basic character- drug abusers over a 25-year period and the ministry of health today estimates istic of stigma. that 30,000 youth become new heroin abusers every year. The Global Fund to Fight AIDS, Tuberculosis and Malaria estimates that there are 2.5 to 3 The root causes of stigma are complex, driven in part by multiple misconcep- million drug users in the southwestern provinces of Yunnan, Xinjiang, tions about the cause of HIV transmission and entrenched distaste for the Guangxi, Sichuan, Guizhou, Hunan and Jiangxi, accounting for about half of socially unacceptable practices of drug use or “promiscuous” sex. The impact the nationwide total. Heroin is the drug of choice for an estimated 86 per- of this stigma is damaging both from a personal and public health perspective. cent of drug users nationally, and is particularly cheap and available in those HIV-associated stigma causes both HIV-positive persons and those at greatest seven provinces. Needle sharing is common because of low risk-awareness risk of contracting HIV to avoid contact with health officials, a behavior that and a lack of available clean needles. Addicts are frequently afraid of being negatively impacts the effectiveness of both prevention and treatment efforts. caught by the police while carrying needles, causing them to discard syringes after use, with no guarantee that they will be able to find a clean one when WOMEN BEAR THE BRUNT they need it next. Women in China generally experience more intense HIV-associated stigma ZERO TOLERANCE AND STIGMA than men. Social traditions, which admire female chastity and male promis- cuity and virility, effectively place greater blame on women for engaging in Drug use takes place in an environment of intolerance and significant stigma the behaviors that contribute to the spread of HIV. Women, who engage in that only magnifies the stigma of HIV-positive drug users. Modern China’s drug use, “promiscuous” or transactional sex, engender more contempt and approach to combating drug trafficking and drug abuse is significantly influ- social rejection than the male clients of sex workers or men who abuse drugs. enced by historical perceptions of China’s victimization at the hands of for- Moreover, sex workers are more visible than their clients which increases eign powers in the 19th and 20th centuries. Following two “opium wars” in attention to them, both by police as well as well-intentioned public health 1839-42 and 1856-60 and the “unequal treaties” that forcibly opened China authorities and NGOs. While health education and “social marketing” of con- to foreign trade and unfettered importation of opium, as many as 13 million doms should not be discouraged, intense attention placed on sex workers Chinese became addicts by the turn of the 20th century representing 27 per- reinforces stigma, and even blame them for the spread of HIV to what many cent of adult males. Using draconian but effective measures following their refer to as the “general populations,” which includes the clients of sex work- victory in 1949, the communists succeeded in eradicating drug abuse until ers. While public health interventions in China have had some success edu- the government began opening its society 30 years later. Today, HIV-positive cating sex workers and their managers at the places they work, inadequate drug users who have managed to keep their HIV status secret, even those attention has been focused on the “johns,” who are the key “bridge popula- who have quit using drugs or have access to methadone, face intense discrimi- tion” between a high-risk group (the sex workers) and a low-risk group (wives nation and stigma, partly because of this historic legacy which influences and girlfriends). A “john school” for persons soliciting sex workers is a poten- modern attitudes. tial intervention which has not been attempted in China yet. Lastly, the wives and partners of both drug users and the clients of sex workers, the Drug users face the constant threat of arrest or detention in compulsory most innocent victims of HIV, are often neglected by health services target- detoxification centers with detention terms of up to 12 months, or in re-edu- ing high-risk individuals, yet once partners become affected by HIV/AIDS, cation through labor centers operated by the justice bureaus with even longer Continued on page 22 terms. A positive drug-test result or even carrying a needle is often enough to warrant incarceration. Because most drug users have been arrested or Global AIDSLink — 9 STIGMA — CONTINUED FROM PAGE 9 they face the added burden of stigma and discrimi- to place as many as 300,000 addicts on methadone, centrates on not only the medical needs of HIV-pos- nation. which will expectantly break the chain of HIV trans- itive individuals and prevention education and care mission through needle sharing. In rural areas where for affected family members, but the social and eco- AN EXPANDED GOVERNMENT methadone is impracticable, some local clinics pro- nomic needs of at-risk communities. The advent of RESPONSE – MORE IS NEEDED vide clean needles to addicts to reduce sharing and methadone and antiretroviral therapy in southwest reuse of equipment. China will constructively shape the future of the The 2003 outbreak of Severe Acute Respiratory HIV/AIDS response by improving the long-term Syndrome (SARS), dramatically demonstrated to The government has invested heavily in mass-com- prospects for affected individuals. This will in turn the Chinese leadership that an out-of-control epi- munications campaigns to raise awareness about the ultimately enhance the effectiveness of critical pre- demic can have economic, social and even political transmission routes of HIV/AIDS and the dangers of vention initiatives including HIV-testing and preven- impacts, prompting them to undertake a more visi- drug abuse, contributing to the de-stigmatization of tion education. ble and determined response to HIV/AIDS. By late the disease. Nationwide campaigns led by noted 2003 the government began increasing national and celebrities, such as basketball star Yao Ming and While efforts such as the Yao Ming campaign are provincial budgets, strengthening policy, and making actor Pu Cunxi exhort Chinese not to shun HIV- laudable, HIV will be tangibly de-stigmatized when high-profile visits to AIDS wards and heavily affect- positive persons and inform the public that HIV is programs help heroin abusers kick their habit and ed villages. The government established a program, not transmitted through casual contact. Posters in gain job skills, making them productive members of known as “China CARES” to distribute free anti- many cities explain how HIV is transmitted, and society. However, to ensure success, the government retroviral (ARV) drugs in provinces where unhygien- most importantly, how it is not transmitted. In heav- will have to roll up its sleeves and work more closely ic plasma donation practices in the early 1990s ily impacted areas, village governments paint AIDS with affected persons. Mass media is inherently pas- caused a major HIV outbreak. This year, free ARVs and drug awareness slogans on walls. While the gov- sive and will not change entrenched behaviors as are now being made available to HIV-positive drug ernment’s increased efforts to control the effectively as face-to-face counseling and personal users and their partners in southwestern provinces. HIV/AIDS epidemic in southwestern China are outreach. Prevention as well as treatment activities The senior leadership has promoted a prevention admirable, immense challenges remain as the inci- must be carried out among high-risk populations so agenda as well, including harm reduction measures dence of HIV continues to rise among drug users that the root causes of HIV/AIDS, including drug such as methadone therapy clinics, which are rapidly and their partners. use and unsafe sexual practices will be addressed. becoming a key component of the government’s Addressing those root causes as well as reducing the strategy. From a modest nine methadone pilot sites, Any successful approach to preventing the spread of stigma that hobbles HIV/AIDS interventions will be the ministry of health plans to expand to 100 clinics HIV in areas where intravenous drug use and com- critical to the ultimate success of the national effort. by the end of 2005, and to open up to 1,500 clinics mercial sex work are the primary mode of transmis- in the next three years. These clinics eventually aim sion will require a comprehensive approach that con HEALTH AND CHILD SURVIVAL FELLOWS PROGRAM Health and Child Survival Fellows Program (HCSFP), Johns Hopkins University Institute for International Programs, prepares junior and mid-career health professionals for careers in international health and child survival. Candidates for specific assignments are selected from a pool of applicants. All HCSFP assignments require U.S. citizenship. HCSFP offers two-year HCSFP offers MPH scholar- HCSFP offers paid student HCSFP offers Urban Child practice-oriented Fellowships ships to candidates with rare internships when available. Survival Fellowships with with the U.S. Agency for qualifications who will add the Baltimore City Health International Development needed skill sets to the Department. (USAID) or similar agencies. program. To learn about current fellowship and internship opportunities visit our website: http://jhuhcsfp.org or contact the National Secretariat by phone 410-659-4108. HCSFP is a USAID-funded program Urban CSFP is funded by Baltimore City Johns Hopkins University is an Equal Opportunity Employer 22 — Global AIDSLink
"drug awareness slogans"