The Peoples Republic of China

The Peoples Republic of China is home to 1.3 billion people, and is arguably the most important HIV prevention site on the planet. China’s HIV epidemic is one of the fastest growing in the world. Experts believe that the number of people living with HIV/AIDS in China could reach 10 million by 2010 if no effective countermeasures are taken. The Chinese Ministry of Health has estimated that 1.1 million people have been infected, and more than 200,000 people have progressed to a later stage of infection or have died. One national survey estimated that as many as 260,000 children may be orphaned by HIV/AIDS by 2010.

In China, total adult HIV prevalence is under 0.1%, but the annual increase in numbers of reported cases has exceeded 30% since 1998, and high rates of HIV have been found among populations of injecting drug users – 35% to 80% in Xinjiang and 20% in Guangdong – and in communities where unsafe blood-collection practices occurred in the 1990s. In 2003, the major transmission routes for HIV are injection drug use (51%), unsafe blood collection (21%), and heterosexual transmission (8%).

At least 3 (and more likely 5) related HIV epidemic patterns have been recognized. First, in the early 1990s intravenous drug users (IDUs) in border areas in South and Western China became HIV infected, and it is believed that these HIV-positive IDUs may serve as a bridge to the general population.

Second, HIV has been detected in 1-10% of professional and part-time (gray market) sex workers. Currently, it is estimated that there are between 3-6 million female sex workers in China. Third, in at least seven central provinces, commercial blood plasma donation schemes inadvertently led to transmission of HIV to the donors. Infection was acquired by poor farmers when they donated plasma for compensation, and leftover plasma was pooled and then re-injected into the donors. Henan, a province with 70 million people, is the epicenter of this tragedy. A study of a village in Wenlou County in Henan, found that 60% of villagers were infected. A million or more people appear to have become HIV infected through blood plasma donation, and “AIDS villages” for AIDS orphans began to surface as early as 1997.

Two other potentially important epidemics are ill-defined. Because of the stigma associated with homosexuality, the number of gay men in China and the prevalence of HIV in this population is unknown. In 2000, one-third of people hospitalized with AIDS in one Beijing hospital appeared to have acquired HIV from homosexual encounters, but 80% of gay men in China are married, and one survey found that less than 10% report condom use with either homosexual partners or their spouses. Finally, more than 120 million people in China have joined the “floating population”, migrating alone or with their families to urban areas for employment. The HIV prevalence in the floating population is unknown, but STIs appear to be very common. In one recent study, 13% of migrant women working in small businesses had untreated Chlamydia infection.

CFAR Collaborations in China

UNC faculty have a long history of collaboration in China. Drs. Henderson and Cohen lived in Wuhan in 1979 and worked with Dr. Gui Xi-en of Wuhan University, an infectious disease specialist who was recognized in 2004 as one of the 10 most important people in China because of his work on HIV. Drs. Cohen and Henderson have collaborated with researchers from the China CDC (formerly the Chinese Academy of Preventive Medicine), Peking Union Medical College, Chinese Academy of Science, Chinese Institute of Virology, and the Nanjing National Center for STD Prevention and Control. Dr. Cohen serves as Chair of the CIPRA Scientific Advisory Board (SAB), and Drs. Cohen and Henderson have participated in all of the major HIV meetings in China. Dr. Swanstrom has represented the UNC CFAR in several meetings and collaborations. UNC will serve as mentor to the China CTU Application.

Dr. Cohen has launched a novel HIV surveillance project in Guangxi Province, using newly developed biological tools. In recognition of future work in STD/HIV research, UNC has developed a formal relationship with the Nanjing National Center for STD Prevention and Control. The UNC/Nanjing collaboration is hosting an NIH Fogarty Ellison Fellow (Dr. Charles Lin, UCSF) in 2005-2006.

Two of the NIH network sites, HPTN and CIPRA, are located in Xinjiang and Guangxi provinces. In the HPTN, for which FHI serves as the network coordination and operations center, the China sites have completed one prospective cohort study to prepare the site for HPTN 058, a Phase III randomized controlled trial to evaluate the efficacy of buprenorphine/naloxone drug treatment in prevention of HIV infection among opiate dependent injectors.

FHI has also provided assistance to the Bill and Melinda Gates Foundation in assessing HIV prevention program needs in China and has provided consultation on the Foundation’s plans for supporting HIV prevention efforts in that country including consultation on how to address HIV prevention service, research, research translation and program evaluation needs. Gary West and Dr. Robert Magnani from FHI led the assessment and UNC’s Drs. Henderson and Cohen provided expert consultation.

The recent NIH supported HIV/AIDS research activities in China require a strong commitment to ethics training for researchers, and the development and training of central and local level IRBs responsible for review of HIV/AIDS research. Dr. Henderson collaborated with UCLA CFAR/Fogarty and the China CDC in developing and conducting a week-long ethics course held in Beijing in 2002. Participants were HIV researchers from nearly every province in China. In March 2003, Dr. Henderson led a group of three UNC faculty to teach a week-long course specifically targeted at IRB training, supported by a UNC Fogarty AITRP supplement. The newly formed IRB at the China CDC National Center for HIV/AIDS Prevention and Control (NCAIDS) worked closely with UNC faculty to develop the course topics and materials, which were translated into Chinese.

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