In China, an About-Face on AIDS Prevention

By Edward Cody
Washington Post Foreign Service
Wednesday, December 8, 2004; Page A26

GUANGAN, China -- Li Yi squirmed a little as she searched for the right words. Using condoms is important to staying healthy, she wanted to say, but pleasing men is also important if she wants to stay in business.

"You know what we do, right?" she asked with a wan smile, settling on a question as a way to make herself clear. "But now, we insist that our customers wear condoms, even when they don't want to."

Li, 19, is one of more than 300 "peer educators" in the flourishing sex industry of Guangan, an agricultural hub of 200,000 people about 275 miles east of Chengdu in central Sichuan province. Picked and trained by AIDS activists working with local authorities, she has been converted to condoms and assigned to encourage other prostitutes to follow suit to reduce their risk of contracting and spreading the AIDS virus, HIV.

"This is a big thing for us," Li said to a visitor who stopped by a downtown "entertainment center" along with several Guangan health officials, who show up at least once a month to deliver free condoms and urge caution.

The status conferred on Li was one step in a broad anti-AIDS campaign in Sichuan and Yunnan provinces, carried out by Britain's Department for International Development and the Chinese Health Ministry. The open attack on AIDS here -- and elsewhere in China through foreign and domestic programs -- has departed markedly from earlier reluctance to face the danger presented by the disease to the country's 1.3 billion people.

Partly as a result of international prodding and partly as a result of last year's experience with SARS, or severe acute respiratory syndrome -- when sickness spread while officials dissembled -- the government increasingly has pushed AIDS prevention out of the closet.

President Hu Jintao dramatized the shift last week by visiting AIDS patients at Youan Hospital in Beijing accompanied by television cameras, matching a similar visit last year by Premier Wen Jiabao. Hu's gesture led the news on government-controlled television and in the press. Officials and newspapers discussed the disease at length in observation of World AIDS Day on Dec. 1, and authorities across the country used the occasion to announce measures to check the disease and detect those who carry the virus.

The Health Ministry said it had increased financing for AIDS prevention to $12 million, up from $1.8 million three years ago. In Beijing, where the known number of HIV carriers has risen by 40 percent a year since 1998, to more than 2,000, authorities hung anti-AIDS posters in the Sanlitun bar district and announced they would distribute free condoms. Shanghai authorities made a similar announcement, and an anti-AIDS spot featuring basketball stars Earvin "Magic" Johnson, who has HIV, and Yao Ming played on government television.

The effort to go public and intensify prevention is timely, Chinese and international specialists say.

As late as the 1990s, statistics showed the disease was largely confined to intravenous drug users and a group of peasants who became infected when they sold their blood. But the number of those known to be infected by HIV has climbed by 75 percent annually over the last four years, reaching an officially estimated 840,000 and, specialists say, probably many more.

More alarming, they say, the proportion infected through sexual contact has also risen sharply, presenting a danger that AIDS will break into the general population -- the world's largest -- and spread in a pattern seen with devastating consequences in Africa. If that happens, the Joint United Nations Program on AIDS has warned, China could have 10 million to 20 million people infected with HIV by 2010.

Openly combating AIDS has not come easily to the governing Communist Party. Since taking over in 1949, it had largely eradicated prostitution, imposing a civic code in which drug use or sexual promiscuity were taboo. Even to deal with AIDS, officials at all levels have found it hard to acknowledge that prostitution is now booming, as are intravenous drug use and promiscuity.

In addition, discussing prostitution and condom use is out of place in much of the country's traditional rural society. The 60 percent of the population that lives in villages and small towns includes millions who travel to big cities temporarily to look for work, often as single men.

A Health Ministry survey issued last month showed that only a fraction of the population understands how AIDS is transmitted and that fewer than half are aware of the role of condoms in reducing the risk of infection. About 59 percent of those queried said they would not work with an HIV-infected colleague for fear of contracting the disease, the ministry reported.

Peasants are not alone in their attitudes. An announcement by Beijing municipal authorities that they would hand out free condoms on college campuses generated immediate counter-announcements by Beijing University and Tsinghua University. Officials at the country's two most prestigious universities said they would not allow condoms to be distributed on campus because it would be tantamount to authorizing premarital sex.

Similarly, an announcement by government-run television that it would sponsor a late-night discussion of sexual matters, including AIDS prevention, carried a proviso that guests would wear masks to conceal their identity.

Zhou Daoyun, a public health physician who runs the China-UK HIV/AIDS Project in Guangan, said the key to overcoming such hesitation was enlisting help from local authorities such as police and disease prevention officials. Gestures such as those made by Wen and Hu -- indicating the country's highest authorities take AIDS seriously -- were important in convincing officials that getting involved was a good idea, he said.

Guangan, birthplace of deceased Chinese leader Deng Xiaoping, is as conservative as any small Chinese town. Zhou said the city did not immediately embrace the aggressive anti-AIDS campaign, which also includes training for medical personnel and help in detecting HIV carriers. But encouraged by their superiors in the provincial government, officials have come around in the last two years, he added.

"In the past, we never promoted the use of condoms, and the government didn't pay much attention to the problem," Zhou said. "Now it's totally different."

Working with Guangan's police and its Center for Disease Control, Zhou and a half-dozen people sponsored by the joint British-Chinese campaign started out by organizing a map showing the city's 155 beauty parlors, bathhouses, hotels and nightclubs where prostitutes work. Each place was assigned a number, which was then pinned to its site on the map, and activists visited repeatedly to hang posters, hand out condoms and encourage prostitutes and their employers to receive training.

"We did it over and over again," said Zhou, 58, who has been involved in public health for 35 years.

A survey of the sites when the project started in 2001 showed that 15 percent of the prostitutes used condoms and 27 percent were infected with venereal disease, including 10 women with AIDS. A survey in October showed that 84 percent use condoms and 17 percent are infected with venereal disease, including six women with AIDS.

"The high-risk people, they now know about AIDS," Zhou said.

© 2004 The Washington Post Company