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					                                                                                                         September/October 2005 — #93

     G L O B A L                             Injecting and Infecting; Stigma and Zero Tolerance in China . . . . . Page 8


                                             Building Healthy Bridges in India . . . . . . . . . . . . . . . . . Page 12
                                             Watching from the Shore . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 15


                                                                                                                 The Second
                                                                                                                    Wave of

                                                                                                                           IN ITS      PATH
                                                                       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

  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

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