HIV in China : Understanding the Social Aspects of the Pandemic 9781742231709, 9781742231693

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HIV IN CHINA

HIV IN CHINA Understanding the Social Aspects of the Epidemic

Edited by Jing Jun & Heather Worth

UNSW PRESS

A UNSW Press book Published by University of New South Wales Press Ltd University of New South Wales Sydney NSW 2052 AUSTRALIA www.unswpress.com.au © UNSW Press 2010 First published 2010 10 9 8 7 6 5 4 3 2 1 This book is copyright. While copyright of the work as a whole is vested in UNSW Press, copyright of individual chapters is retained by the chapter authors. Apart from any fair dealing for the purpose of private study, research, criticism or review, as permitted under the Copyright Act, no part may be reproduced by any process without written permission. Inquiries should be addressed to the publisher. National Library of Australia Cataloguing-in-Publication entry Title: HIV in China: understanding the social aspects of the epidemic/ editors, Heather Worth, Jing Jun. ISBN: 978 1 74223 169 3 (pbk.) Subjects: HIV infections – China. AIDS (Disease) – China. HIV infections – China – Prevention. AIDS (Disease) – China – Prevention. HIV infections – Government policy – China. AIDS (Disease) – Government policy – China. HIV infections – Social aspects – China. AIDS (Disease) – Social aspects – China. Other Authors/Contributors: Worth, Heather. Jing, Jun. Dewey Number: 362.196979200951 Design Avril Makula Cover Elizabeth Carey Smith Printer Ligare This book is printed on paper using fibre supplied from plantation or sustainably managed forests.

Contents Acknowledgments Notes on Contributors

vii ix

Introduction: Building HIV Social Research Capacity Jing Jun and Heather Worth

1

1 An Overview of China’s HIV Epidemic Jing Jun and Heather Worth

11

2 Female Sex Workers in China: Their occupational concerns Huang Yingying

43

3 Drugs, HIV and Chinese Youth Jing Jun

67

4 ‘Red Oil’: Blood and the role of a machine in the HIV outbreak in central China Su Chunyan

101

5 Fears of Identity Exposure among Gay Men Living with HIV Zhang Yuping

117

6 Disclosure and Condom Use after HIV Diagnosis Sun Yongli

139

7 The Central Place of the Chinese Family in HIV Narratives He Mingjie

159

8 Stigma and HIV Discourse in China Zhang Youchun

175

9 Ethnicity and Gender in Social Research on HIV in China Huan Jianli

195



219

Index

vi

Acknowledgments Angela Kelly, Patrick Rawstorne, Catherine Spooner at the University of New South Wales and Rachael Hamed played a key role in the preparation of the present book’s publication. Other people who have helped make this publication possible include Cheng Feng, Wang Ruotao, Pan Suiming, Zhuang Kongshao, Jin Wei, Zhang Yun, Zhang Jun, Wang Qihua, Chen Yue, Wang Ning and Ai Wenming. We owe all of these warm-hearted individuals a deep debt of gratitude. We also thank institutions that have supported the collaboration between the University of New South Wales in Australia and Tsinghua University in China to enhance capacity in Chinese social research on HIV. These institutions include the Australian Embassy in Beijing, the Fellowships Program of the Australian Leadership Awards under AusAID, the Australian HIV Consortium (also funded by AusAID), the Chinese National Center for STD/AIDS Prevention and Control, the Bill & Melinda Gates Foundation, the Yunnan Provincial Association for STD/AIDS Prevention and Control, Yunnan University, Sichuan University, the Chinese People’s University and Xinjiang Normal University. We also want to thank the Chinese National Center for

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STD/AIDS Prevention and Control, China CDC and the Ministry of Science and Technology in China for support through a research grant (No. 2008ZX10001-003), which enabled us to collect information on the local situation of the HIV epidemic in China from 2008 to 2010. Our final thanks go to the University of New South Wales Press who agreed to publish this book and waited patiently for our manuscript to arrive.

viii

Notes on Contributors Professor Jing Jun is a Sociology Department professor and Director of the Social Policy Research Centre at Tsinghua University in Beijing. He is a policy advisor for the Chinese National Center for STD/AIDS Prevention and Control, and the China–UK HIV/AIDS Prevention and Care Project. Associate Professor Heather Worth heads the International HIV Research Group in the School of Public Health and Community Medicine at the University of New South Wales, Sydney Australia. Her team carries out HIV social research and research training in many countries in Asia and the Pacific. Huang Yingying has a PhD in sociology from the Chinese People’s University and now serves as associate director at an institute for research on sexuality at the Chinese People’s University. Her research has primarily focused on women in China’s sex industry.

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Su Chunyan received her PhD in sociology from Tsinghua University in 2009. She is now a lecturer of social studies in the School of Journalism at the Chinese Youth College of Political Sciences. She is also on a technical support team for a Gates Foundation-funded program for HIV prevention among Chinese gay men. Zhang Yuping was junior researcher at the AIDS Policy Research Centre at Tsinghua University from 2006 to 2010. She is now a PhD candidate in the Department of Sociology at Tsinghua. Her research interests cover social mobility among migrant workers in Chinese cities and social marketing of rapid HIV tests. Sun Yongli received her PhD in social anthropology at the Central University of Ethnic Minorities in Beijing in 2007 and then served as post-doctoral researcher at the Chinese National Center for STD/AIDS Prevention and Control. She is now a lecturer in the Division of Health Management and Education at the Capital Medical University in Beijing.

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notes on contributors

He Mingjie has a PhD in sociology from Tsinghua University in Beijing. She is now a lecturer in the Department of Sociology and Social Psychology at Sichuan University in the city of Chengdu. In addition to her research on HIV, she leads a regional project for suicide prevention among rural women in Sichuan. Zhang Youchun has a PhD in social anthropology from the Central University of Ethnic Minorities in Beijing. He worked as a policy analyst at the Chinese National Center for STD/ AIDS Prevention and Control from 2005 to 2007. He is now a full-time researcher at the Institute for Anthropological Research at the Chinese People’s University. Huan Jianli is an associate professor of Sociology in the Division of Humanities and Social Sciences at Beijing Science and Technology University. His current research is concerned with social suffering of elderly patients in rural China.

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LAOS

VIETNAM

Ya n g

GUANGXI

Beijing

Hong Kong

GUANGDON

Shenzhen

ive

SEA

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0

J A PA N

SEA OF

PH I L I P PI N E S

TA I WA N

SEA

ur R

Am CHINA

EAST

SOUTH KOREA

KOREA

NORTH

Shanghai

Nanjing

ANHUI

Fuyang

ua

Shenyang

S

h ong

Y E L LOW

SOUTH CHINA SEA

ste

Zhumadian

HENAN

Ye l l o w

Pe a r l R i ver

GUIZHOU

Kaiyuan Gejiu

Kunming

Leshan

SICHUAN Chengdu

GANSU

MONGOLIA

YUNNAN

THAI.

MYANMAR

er

B AY O F B E N G A L

BANGLA.

M

iv g R

INDIA

BHUTAN

XINJIANG

Urumqi

n ko

N EPAL

UZBEKISTAN

K A Z A K H S TA N

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RUSSIA

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K I L O M E T R E S

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PACIFIC

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Introduction: Building HIV Social Research Capacity Jing Jun and Heather Worth

A

lthough China’s first case of HIV was diagnosed in 1985 and by the late 1990s hundreds of thousands of confirmed HIV infections had accumulated, social research in HIV was almost non-existent within the People’s Republic. This was partly because HIV was regarded by the Chinese community of social scientists largely as a medical problem and partly because there was little funding for social research on HIV in China before 2000. Fortunately, however, international HIV programs operating in China later welcomed the participation of social scientists. In particular, the China-UK HIV/AIDS Prevention and Care Project – launched in 2001 and completed in 2007 – encouraged a significant number of social scientists to take part in action research on HIV by performing baseline studies and program evaluations. Now, social researchers within China who have taken up HIV issues include sociologists, anthropologists, health economists, scholars of social psychology and gender studies, as well as researchers in legal studies and public administration. To help China build greater capacity to carry out HIV social research, the University of New South Wales (UNSW) in Australia and Tsinghua University in China began to explore areas of collaboration in 2008. Subsequently, the two universities

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selected ten Chinese social scientists to attend a specially designed month-long HIV social research training workshop, first conducted in Beijing and then in Sydney. Aimed specifically to train younger Chinese scholars, the workshop included nine Chinese researchers in their 20s and early 30s. The present book is one of the outcomes of the Beijing– Sydney workshop and subsequent AusAID funding through the Australian HIV Consortium; all the contributors to the nine chapters participated in the workshop. This book is an outcome of that workshop. This book on the social aspects of China’s HIV epidemic takes the position that HIV is not purely a medical problem. In fact, while and because HIV is spread through blood, sexual f luids and breast milk, it is a disease which is laden with real and symbolic power. We believe that HIV is a social, cultural and political problem for which we jointly have to find solutions that are based in local situations. While there has been a hierarchy of research evidence which has privileged the clinical and the epidemiological over the social, since the HIV epidemic began, social research has played an important part in how we have come to understand HIV and has been central in the evidence of how to best respond in different contexts. In an interview with Mykhalovskiy and Rosengarten (2009), Susan Kippax states that without embracing social and cultural theory it is impossible to understand the social and cultural production of sexual practice and how to intervene socially to change

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Introduction

sexual risk. The social and the cultural are critical to understanding the many different HIV epidemics throughout the world. So, in this book the authors have emphasised the social aspects of HIV through local understandings of social settings – the environments in which HIV infection occurs and in which the impact of HIV is felt. This is ref lected in the ways the authors write about the lives of those most at risk of HIV – the social and cultural contexts in which they come to be affected by and infected with HIV, how they are treated in their communities and by authorities, health systems and the media. Jing Jun at Tsinghua University and Heather Worth at UNSW wrote the book’s first chapter, which serves as an overview of China’s HIV epidemic and emphasises the function of inequality in the epidemic’s outcomes. Jing Jun and Heather Worth argue that China’s HIV epidemic – until recently – closely followed two socioeconomic paths. On the one hand, the epidemic was propelled by three economic drivers: the blood trade, the drug trade and the sex trade. On the other hand, the epidemic progressed at the cost of three socially marginalised populations: impoverished rural residents in central China, ethnic minorities in border regions, and female migrant workers in many Chinese cities. Recent discoveries of an alarmingly high HIV prevalence among Chinese male homosexuals have added greater complexities to the country’s HIV epidemic.

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Chapter 2 by Huang Yingying deals with the Chinese sex industry. Huang argues that the Chinese strategy for HIV prevention suffers from a narrowly defined concept of risk and operates at the cost of ignoring a complex set of other concerns among female sex workers. She contends, for example, that the public health sector’s effort to promote condom use among sex workers, and especially among ‘hair-salon girls’ who are positioned at the lower end of the sex industry, often fails to consider their fears of violence, pregnancy, infertility and identity exposure. This failure remains an obstacle to the country’s prevention of sexually transmitted infections (STIs) and HIV via the sex industry. In chapter 3 Jing Jun explores heroin use among Chinese youngsters. As heroin injecting has constituted a major propeller of China’s HIV epidemic, Jing Jun argues that heroin consumption among Chinese youngsters usually follows certain youthful behaviour, such as smoking, drinking, truancy, multiple sexual relationships, overnighting in internet bars, stealing and gang fighting. As a prelude to injecting drug use, these behaviours are characteristic of a subculture formed through intimate relationships among youngsters who share similar experiences of academic failures in an extremely competitive education system; a string of troubles with authorities, and a need to carve out an identity for themselves. Su Chunyan, in chapter 4, addresses the question of how

6

Introduction

plasmapheresis – a biomedical technology to collect and extract plasma from blood – played a devastating role in the spread of HIV in central China in the late 1990s and early 2000s. Adopted for use in a market of blood sales during the early 1990s, this machinery was used in hazardous ways and led to HIV infections among rural residents who were trying to make an extra income out of paid plasma donations. Su Chunyan argues that the technical risks inherent in the use of plasmapheresis were amplified by social risks. These included a market situation in which trade in blood and plasma was widespread, a political environment in which the careers of government officials depended on local GDP achievements, and a social climate in which attitudes towards selling blood among rural populations changed from something shameful to a way to afford consumer goods. Zhang Yuping tackles the sensitive issue of Chinese gay men living with HIV and how they perceive the importance of confidentiality in chapter 5. Among these men confidentiality is the top concern. Their constant fear is a double exposure: that both their HIV status and gay identity could be exposed by medical providers or social agencies. Once exposed, they fear rejection by the gay community because they have HIV, and by society at large because they are gay. This fear is well founded, Zhang Yuping explains, since breaches of confidentiality with regard to people living HIV are a serious problem in China. Her study was conducted in the city of Chengdu where she

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collaborated with a local gay organisation in applied research in response to a sharp increase of HIV infections among local gay men. In chapter 6 Sun Yongli explores condom use and HIV disclosure after individuals have tested HIV positive. There has been a prevailing belief in the Chinese medical community and news media that deliberate deception and irresponsibility on the part of those living with HIV account for much of the yearto-year increase in the newly discovered HIV infections in China. Her study of 131 respondents in a city in southwestern China shows that barriers to HIV disclosure and condom use involve a ‘principle of psycho-social distance’ that defines a complex set of human relationships. She therefore argues that changes in sexual behaviour should not be expected to be a natural outcome of a sero-positive diagnosis. Nor should failures to engage in HIV disclosure be assumed as a matter of deliberate deception or irresponsibility. The deciding factors for safe sex and disclosure to happen, she says, are the contextualised social relations in which the HIV-positive individuals find themselves. In chapter 7, He Mingjie discusses the centrality of the family in Chinese society. By analysing 71 narratives collected via an oral history project, her study shows that the Chinese family can be a source of tenderness and care in most circumstances, including its encounter with HIV. But it can also be a source of great aff liction. She contends that familial

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Introduction

relations constitute a wide range of multifaceted dynamics that directly affect the quality of life among the people infected with HIV. Her study demonstrates that HIV-related stigma is not only widespread in society in general but also penetrates into the social fabric of a basic source of human intimacy in Chinese society – the family. In chapter 8, Zhang Youchun argues that the source of HIV-related stigma and discrimination in China can be traced to ideas and metaphors associated with the attitudes of government agencies, news media and health professionals. He suggests that stigma itself is a powerful driver of the country’s HIV epidemic because discrimination via denial of employment, residence, education and welfare, as well as personal fear of isolation, ridicule and helplessness, interact with one another and develop into a formidable force of deterrence of safe sex or drug use, disclosure of status and HIV testing. Because of stigma, at-risk individuals are afraid of HIV testing, while those already living with HIV are afraid to inform their intimate partners of their status. Written by Huan Jianli, the book’s concluding chapter is concerned with how Chinese social scientists have dealt with issues of inequality in relation to ethnic minorities and migrant women. His chapter indicates that social research on HIV in China remains a highly sensitive endeavour, as it leads to uncomfortable questions for people in power. In addition, some social research findings have the potential to be sensationalised

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by the news media. Chinese social scientists therefore have had to carefully maintain a fine balance between HIV research and politics, between objectivity and advocacy, and between the necessity to create social awareness through applied research and the need to avoid stigmatising social groups that are already faced with many forms of discrimination. At the end of our preparation of this manuscript, UNSW and Tsinghua University collaborated once again by organising another training workshop for Chinese social scientists. This time, the workshop drew 20 young scholars from Yunnan, Guangxi and Sichuan, once more with the goal of publishing research from young scholars. We are extremely grateful that the collaboration between the University of New South Wales and Tsinghua University has been moving ahead smoothly. We share the belief that Chinese social scientists are central to the evidence-gathering that has contributed to and will continue to help advance China’s HIV prevention.

References Mykhalovskiy, Eric & Rosengarten, Marsha (2009), ‘Commentaries on the nature of social and cultural research: interviews on HIV/AIDS with Judy Auerbach, Susan Kippax, Steven Epstein, Didier Fassin, Barry Adam and Denis Altman.’ Social Theory & Health Vol 7/3, co-edited and introduced by Eric Mykhalovskiy & Marsha Rosengarten.

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1 An Overview of China’s HIV Epidemic Jing Jun and Heather Worth

T

he first case of HIV in China was discovered in 1985. By the end of 2007, the Chinese government had declared that China had a total of 223,501 confirmed HIV cases, although it estimated that 700,000 people were living with HIV in China at this date. This estimate was calculated on the basis of HIV prevalence among five populations at risk: injecting drug users; female sex workers; clients of sex workers; those with sexually transmitted infections (STIs), and paid blood donors ( Jing, 2005). By the end of 2009 this total had risen to 740,000. Considering that China has a population of one billion, its HIV prevalence epidemic is low, but complacency could quickly accelerate the epidemic. This chapter will discuss the unfolding of the HIV epidemic in China. At the outset, we want to note that an energetic response to HIV was lacking in China until late 2003.1 The turnaround in China’s HIV response was due to the combination of two events. First, a new generation of leaders in the Chinese Communist Party and the Chinese central government came to power during the Severe Acute Respiratory Syndrome (SARS) crisis of 2003. Second, the SARS epidemic made these new leaders keenly aware of how a small virus could trigger widespread panic, first in China and then throughout the world.

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We also want to state that HIV is not indiscriminate in its choice of victim, and this applies to China as well. The routes for HIV transmission are behaviourally based, but there is a definite socioeconomic gradient in the ways in which it affects  people. The behaviours rendering certain populations susceptible to HIV very much hinge on that population’s social standing, economic status and everyday experiences of struggling against various adversities. As the following analysis makes clear, the majority of those who have borne the brunt of the HIV epidemic in China live at the bottom of Chinese society. In attempting to improve their lives, they share numerous risks in three markets: the blood trade, the drug trade and the sex trade. These three markets have served as the main drivers of China’s HIV epidemic.

The blood trade Of China’s official tally of confirmed HIV cases accumulated from 1984 to 2007, 23.6 per cent can be traced to the trade in blood and blood transfusions. The huge impact of blood sales in China until recent years underscores the fact that China’s HIV epidemic is unique because of that trade. Trade in human blood began in China after the technology of blood transfusion was introduced by missionary hospitals in major Chinese cities at the turn of the twentieth century. In the first half of that century, voluntary donations of blood were limited to wartime

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situations when army generals called upon soldiers and citizens to give blood for the wounded. With the founding of the People’s Republic in 1949, China’s blood supply was dom­ inated by remunerated sources, supplemented by compulsory donations. Even at the height of socialism under Mao Zedong from the 1950s to the 1970s, an underground blood market existed. China’s adoption of some mechanisms of a market economy in the 1980s led to the expansion of the existing blood trade, bringing it into the open. In 1998, when the National People’s Congress passed the country’s first blood donation law, 78 per cent of China’s total blood supply collection for sur­ gical and other medical purposes was via remuneration. The country’s plasma market that emerged in the late 1980s and the early 1990s co-existed with and in fact depended on the widespread trade in blood. The Chinese legislature passed the blood donation law in 1998 which went into effect in 1999, largely because of the alarming signs of an approaching HIV epidemic linked to the trade in blood and plasma. The Chinese government now claims that the once-thriving trade in human blood for blood transfusion and plasma for making various kinds of medications has been brought under control, and therefore the country’s blood supply no longer poses a threat to public health. But this so-called bygone problem still haunts China. Many of the people who became infected with HIV via the blood and plasma trade are alive and need antiretroviral treatment (ART). In addition, while whole

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blood donation has become voluntary and free of monetary transaction, the collection of plasma for the purpose of producing medications has remained a for-profit business, although safety procedures are much tighter than before as companies in the business of turning plasma into medicine are carefully monitored. The province of Henan in central China is significant with regard to the HIV epidemic driven by the trade in blood and plasma. From 1990 to 1995, blood banks and pharmaceutical companies aggressively sought out local farmers in Henan for plasma, neglecting every hygiene precaution and, as a consequence, causing a devastating HIV epidemic (Anagnost, 2006; Erwin, 2006; Shao, 2006). The city of Zhumadian in southern Henan became a focus of some of the most horrific consequences of the plasma trade. Zhumadian is encircled by rural areas characterised by severe poverty and environmental degradation. Inhabited by some of the poorest farmers in China, these areas were regarded by blood banks as the ideal sites to procure blood at low cost. As the domestic demand for plasma and blood products increased, the Zhumadian-centred blood market extended its reach to other parts of Henan and eventually to six nearby provinces. The origin of the HIV outbreak in Henan is traceable to government policy. In 1984, Chinese customs officials discovered HIV in imported blood products from the United States. That year, doctors also discovered HIV infection among

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Chinese patients who had used imported blood-based medications. In 1985 the Chinese central government decided to ban the importation of plasma completely. Also banned were blood products such as albumin, globulin, platelets and coagulants. This decision was a turning point for China’s pharmaceutical industry. Almost overnight the Chinese plasma market became entirely domestic, with no competition from overseas. Seven institutions under the Ministry of Health that had specialised in research on blood transfusion led the way in the rapid creation of China’s own plasma industry, followed by military hospitals and pharmaceutical companies (He, 2001; Zhang, Ke 2005; Gao, 2005, Wan, 2003). As the potential for profits became apparent, Chinese investors with little experience in the production of medicines entered the plasma industry. At the grassroots level, officials transferred public funds, originally designated for other purposes, into the plasma market by establishing their own companies and networks of blood contractors. By the time the central government intervened in 1995 to regulate the plasma industry by cleaning up the blood market, 579 unregistered businesses throughout China were collecting blood to extract plasma. Another 738 registered businesses were found to be using unsafe collecting procedures. This means that at least 1,300 businesses nationwide were making money out of blood ( Jing, 2006:73). The combination of dire poverty, corporate greed and

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government negligence was, however, only one cluster in the many factors that laid the foundation of China’s plasma trade. For example, blood had long been bought and sold in rural China, but the introduction of centrifuges – the machines to separate blood into red cells and plasma – helped turn the process of blood-for-plasma collection into a highly dangerous one (see Chapter 4). By regulation, these machines, which local farmers called ‘high-speed spinners’, could properly be operated only by trained health workers; they should not have fallen into the hands of local blood contractors. Furthermore, the widespread practice among the plasma collectors to re-inject the unwanted red cells back into the blood-sellers, on the grounds that this enhanced their health and allowed them to give blood more frequently, was a special hazard. This is because the red cells from different donors were pooled together before re-injection. So if one person had HIV, everyone who received the reinjection would contract it as well. We should also take note of ‘clustered infections’ - certain families in a community were infected while other families were not. This phenomenon has been documented by Zhang Ke and Gao Yaojie, two doctors who had treated hundreds of patients who acquired HIV through the blood trade in central China (Zhang, 2005; Gao, 2005). According to them, bloodselling had once been seen as shameful, and blood-sellers used to be regarded as too lazy to make an honest living. Selling blood was therefore kept secret and was not something to brag

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about. But by the early 1990s, China’s market reforms were accompanied by fierce competition in rural communities to show off personal wealth by building new houses, staging extravagant wedding banquets and buying electronic goods such as televisions and washing machines. Thus for many poor families in central China selling blood became a quick way to accumulate wealth. It was the people in these poorer families who became the victims of the clustered infections. There was also another kind of clustering. Namely, some communities were hit badly by the epidemic while other communities in the same region were not. Social geography rather than poverty, made the difference. By social geography we mean the distance between rural communities and blood centres as well as the roads connecting rural communities with blood centres and hospitals which also ran blood businesses. This is precisely what four Chinese researchers discovered in Shangcai county (Henan province), in summer 2002 when they conducted a study of four villages badly affected by AIDS. They noticed that all four villages were located along a paved road connected to the local county seat. They then asked county officials to give them a list of other villages that had also been hard hit by HIV. On checking the list against a local map they found that all the so-called ‘AIDS villages’ were either near the county seat or had easy road access to it. Further interviews revealed that a large blood bank was located inside the county seat and blood vans were

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sent out to find blood-sellers along a handful of the paved roads all connected to the county seat. There were even poorer villages in Shangcai county, but they were spared from the epidemic because they were far from the county seat or not connected to it by paved roads ( Jing et.al., 2002). What is the consequence of the plasma market? In a 2003 proposal for funding submitted by the Chinese government to the Global Fund to Fight AIDS, Tuberculosis and Malaria, it was stated that the plasma trade had extended to 56 rural counties in seven provinces, employing 1.5 million rural sellers of plasma. The Chinese government estimated in this proposal for funding that 250,000 of these plasma sellers had contracted HIV (Global Fund China Office, 2003). One year later, a joint assessment report issued by the State Council AIDS Working Committee Office and the UN Theme Group on AIDS in China stated that blood-sellers constituted nearly a quarter of all the people in China who were living with HIV. Three years later, however, the Chinese government drastically revised this figure downward by declaring that only 57,000 people who were living with HIV in China had contracted the virus through the trade in plasma. Even if we accept the Chinese government’s revised figure of 57,000 individuals infected with HIV through the trade in plasma, it is important to note that this number refers only to paid blood donors. It does not include those who have been infected through blood transfusions or blood products. The

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figure also excludes those paid blood donors who had died. During the first wave of AIDS cases in central China back in 2000/2001, HIV tests were not available at local hospitals. Only about 400 patients from rural Henan, Anhui and Hebei provinces who went to Beijing for treatment received HIV tests. In other words, those involved in the plasma market who had died of AIDS in rural China but never received HIV testing have remained entirely unaccounted for in official statistics.

The drug trade Of China’s official confirmed HIV cases up to 2007, 38.5 per cent was caused by injecting drug use. The HIV epidemic, driven by the trade in illicit drugs in China, has had two centres of gravity: Yunnan in the southwest and the Xinjiang in the northwest. This particular epidemic had its first outbreak in 1989 when 177 heroin injectors in a border town of Yunnan were discovered to be HIV positive (Lu et al., 2008). Yunnan shares long stretches of border with the Golden Triangle in the mountains of Myanmar, Laos, Vietnam and Thailand. As border traffic opened up for trade between China and these countries in the mid-1980s, crime organisations targeted Yunnan as the key route of heroin shipment into China. For about 20 years following the first outbreak of the drug-driven HIV epidemic in Yunnan, injecting drug use

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contributed to most of the province’s HIV infections. It was not until 2008 when unsafe sex, for the first time, caused more new HIV infections than injecting drug use in Yunnan. Like the plasma-driven HIV epidemic in Henan, the drug-driven epidemic of HIV in Yunnan eventually spread to nearby provinces too. In Guangxi and Guangdong, for example, injecting drug-related HIV infections began to show up in large numbers by the late 1990s. By the late 1990s, the province of Sichuan also became seriously affected by the drug-driven epidemic that originated in Yunnan. In Sichuan, the problems of injecting drug use have been most serious in a prefecture called Liangshan. It is connected to Yunnan by mountain passes and trails that became ideal routes for heroin trafficking. But the problem of HIV in Liangshan started elsewhere. Throughout the 1990s many young people belonging to the Yi ethnic group in Liangshan left for urban centres. Some of these youngsters became heroin addicts and petty drug dealers as a result of the fundamental problems of survival characterised by joblessness, ethnic discrimination, language barriers and police harassment in urban centres of southwest China such as Chengdu, Kunming and Guizhou. Injecting drug use and drug dealing became commonplace among these youths. So the HIV epidemic in Liangshan did not originate in the prefecture itself; it started among Yi youth who had moved into urban centres in the southwest and brought the virus back

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to Liangshan. They also brought back alternative ways of making a living through trafficking and peddling narcotics (Ma, 1999; Weng, 2004; Liu, 2007). Xinjiang, the other centre for the drug-driven HIV epidemic, is a relative latecomer. Its first-ever HIV case was diagnosed in 1995. By late 2009, however, a total of 27,000 HIV cases had been reported there. This rapid increase had a lot to do with the rise of the Golden Crescent drug route, located in the mountainous area overlapping Afghanistan, Iran and Pakistan. Although the Golden Triangle bordering Yunnan used to be the world’s largest nucleus for heroin production and shipment, its output of opium was surpassed by the Golden Crescent in 1999. Because it has borders with Afghanistan and Pakistan, Xinjiang was targeted by crime organisations as a corridor of narcotics shipment into China and nearby central Asian countries (Gill & Song, 2006). As in Yunnan, heroin trafficking in Xinjiang led to heroin use, shared use of syringes, and thus the spread of HIV. It is worth noting that Xinjiang has a population of 20 million, and that 60 per cent are ethnic minorities. The Uyghur people, among a total of 46 ethnic groups in Xinjiang, are the hardest hit by the drug-driven HIV epidemic. The HIV epidemic driven by the trade in illicit drugs, especially heroin, has badly affected some of China’s ethnic minorities. In 2000, Yu Xin, a well-informed Chinese expert

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on mental health, revealed in a journal article that 36 per cent of the people living with HIV in China were ethnic minorities whereas ethnic groups made up only 8 per cent of the country’s total population (Yu, 2006). Yu Xin did not disclose where this sensitive information came from, but his figure was later widely cited in discussions on the HIV epidemic’s impact on the country’s ethnic groups. In the official compilation of HIV statistics at the national level, the ratio of Han Chinese and ethnic minorities among the people living with HIV has been consistently fudged due to its political sensitivity. This partly explains why China’s strategy for HIV prevention has avoided issues of ethnicity. Moreover, in order to attract investment into areas populated by ethnic minorities, local officials in charge of these areas have tried to hide the true extent of HIV infection. And yet, statistics that have been collected by local health workers in Yunnan, Xinjiang and Sichuan reveal that the HIV epidemic is highly selective. In Yunnan, ethnic minorities represent 34 per cent of the province’s total population. But in 1989, when the first HIV outbreak was documented there, 92 per cent of the people who tested positive turned out to be ethnic minorities. In 1995, when the blood samples of more than 80,000 people were tested for HIV in Yunnan, it was found that ethnic minorities made up 49.6 per cent of those who tested positive. It was only 16 years later that the makeup of HIV-positive people in Yunnan became more or less

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proportional to the province’s ethnic composition. In Xinjiang, where the first HIV case was found in 1995, more than 90 per cent of the reported HIV cases accumulated by 2008 were those of ethnic minorities. And in Sichuan, where the first HIV case was discovered in 1991, the Yi ethnic group in Liangshan prefecture mentioned earlier, contributed to 48 per cent of Sichuan’s total HIV-positive population by 2007. In each of these examples, the first wave of the HIV epidemic and the initial phase of its eventual spread hit ethnic minorities hardest. Hou Yuangao, a sociocultural anthropologist based in Beijing, has tracked the increase in HIV in regions of ethnic minorities. He urged the central government to allocate more financial resources to these regions for poverty relief, because he be­ lieves that poverty is the underlying driver of the HIV epidemic among ethnic minorities. The trade in heroin and the consumption of heroin are only the surface manifestations of poverty (Hou, 2009). Other Chinese anthropologists also warned that those regions demographically dominated by ethnic minorities were bound to be among the first group of localities to succumb to the consequences of the country’s HIV epidemic. Ma Lianying at the Institute of Ethnology of the Sichuan Academy of Social Sciences, Zhuang Kongshao at the Chinese People’s University in Beijing and Weng Naiqun at the Institute of Ethnology of the Chinese Academy of Social Sciences, for example, repeatedly issued warnings in this regard. These scholars have noted that

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China’s ethnic populations are found primarily in border areas, and notably in mountainous regions ill-suited to agriculture. In these regions, poverty and HIV are closely related (Ma 1999, Weng 2004, Zhuang, 2005). For example, in the prefecture of Liangshan in Sichuan, 11 of its 17 rural counties are officially classified as ‘impoverished areas’. With a combined population of 5.6 million, these counties are affected by a difficult climate, poor transportation, rudimentary infrastructure and economic underdevelopment.2 In these impoverished areas, the lucrative trade in narcotics offered an alternative means of economic improvement for some among the ethnic minorities living there. This was especially the case for many of the young men of the Yi nationality who migrated to cities where they could not find jobs, eventually engaging in petty crime to make a living. Trading small parcels of heroin was one of the most common ways for these young men to make ends meet. The usual sequence for these youngsters to have become infected with HIV was by testing the ‘merchandise’s quality’ by using it themselves and ending up addicted to heroin. These young people started using heroin orally but eventually switched to injecting. They also shared heroin with close friends or fellow dealers. When there was only one needle or syringe, they took turns in using it. And if one of them was infected with HIV already, these needle-sharing practices became a vector of HIV transmission (Liu, 2007).

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In addition, tourism in Yunnan was officially identified by local officials as a niche for economic development, as the province has many rivers and mountains unspoiled by industrialisation. To promote tourism in Yunnan, women of ethnic minorities were offered as objects of sexual fantasy in travel articles and guidebooks so as to satisfy the thirst of male tourists for exoticism. Local officials, in their drive to stimulate the economy, went as far as to conclude privately that as long as the sex trade linked to the tourist industry did not disrupt public order, it should not be curbed by local police. What followed was a proliferation of massage parlours and little hotels where sexual services could be obtained for a very low price (Ma, 1999; Wang, 2003; Hou, 2009). However, if our analysis is conducted solely in terms of the Han Chinese majority and the ethnic minorities, we risk being left with an over-simplistic view of what is actually a set of complicated problems. In other words, all ethnic minorities in China do not suffer from the identical degree of marginality and vulnerability. And the same applies to the spread of HIV. For example, in Yunnan, ethnic minorities made up 32 per cent of those who were HIV-positive in 2003. But the Dai, who constituted only 2.7 per cent of the province’s entire population, contributed to 13 per cent of those with HIV in the province in 2003. Similarly, the Jingpo in Yunnan contributed to 6 per cent of the province’s reported HIV infections in 2004, while they made up only 0.31 per cent of the total population

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in Yunnan. In Sichuan likewise, the infection rate among ethnic minorities also greatly exceeds that of the Han Chinese population proportionally, but that does not mean that all ethnic minorities in Sichuan are equally threatened by HIV. For example, in Sichuan the Yi, who made up only 2.6 per cent of the province’s entire population, contributed to 33 per cent of all the reported HIV infections in Sichuan in 2008. Very much like the situation in Sichuan, the Uyghur ethnic group in Xinjiang constituted 46 per cent of the region’s population and yet made up 80 per cent of the region’s cumulative number of HIV cases by 2008. While the fact remains that some of the country’s ethnic minorities have borne the brunt of the first wave of this regionalised drug-driven HIV epidemic, Chinese health officials are still extremely reluctant to talk about the close association of drugs, HIV and ethnicity because of the potential of such discussions to provoke questions about the effectiveness of the national government’s pledge to protect the rights of ethnic minorities and promote equal opportunities for socioeconomic development. In addition, as a cultural anthropologist points out (Hyde, 2007), many Han Chinese government officials and health workers view and conduct HIV prevention with a heavy dose of cultural bias against ethnic minorities, blaming them as the main vectors of the disease. This view is based on a Han Chinese belief that ethnic minorities are more prone to promiscuity and that the border

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AN OVERVIEW OF CHINA’S HIV EPIDEMIC

regions where many ethnic minorities live are fraught with various kinds of danger, including drug addiction and uncommon infectious diseases. So to acknowledge the extent of HIV in ethnic minority communities requires a two-front battle. The persistent bias regarding ethnic minorities must be dispelled. At the same time, injecting drug use, prostitution and unsafe sexual behaviours in areas inhabited by ethnic minorities should be taken seriously. Since this is a rather delicate issue for public discussions that could cause a backlash, the trend among officials, health workers and journalists in China has been one of avoidance and silence. Above all, the high-level policies that guide the country’s overall response to the HIV epidemic have lacked the recognition that ethnic minorities have suffered a great deal.

The sex trade Injecting drug use was the leading cause of HIV infections in China before 2003, but the situation then began to change. By 2007, the number of newly discovered HIV infections acquired through sexual contact surpassed those acquired through injecting drug abuse, rising to 41 per cent of all infections recorded in the first 10 months of 2007. At the time, less than 4 per cent of these sexually transmitted HIV diagnoses were traced to men who have sex with men. In other words,

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unprotected heterosexual sex became the dominant driver of the country’s overall HIV epidemic by 2007 (State Council AIDS Working Committee Office, 2007). Propelling the increase of new HIV infections due to unsafe heterosexual practice was the country’s sex trade. In 2004, Chinese Public Security sources estimated that there could be as many as 10 million female sex workers in China (Huang, 2004). And according to China’s Ministry of Health, UNAIDS and WHO, approximately 127,000 female sex workers and their clients were living with HIV in 2005, accounting for nearly 20 per cent of the total number of estimated HIV cases across the country (Ministry of Health, UNAIDS & WHO, 2006). At China’s Centres for Disease Control (national estimation meeting in 2007, health officials from Guangdong estimated that the province had half a million prostitutes. Health officials from other provinces reported much lower estimates.3 While trade in sex exists all over China, it has had its most thriving business in Guangdong province. For many years after the opening up of the urban Chinese economy in the mid1980s, Guangdong led the country in creating an exportoriented economy. The province also was first in allowing women to work at recreational establishments such as nightclubs and karaoke bars to entertain international and Hong Kong businessmen. Because their interaction with the customers was characterised by the three roles of companionship – drinking,

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singing and dancing with ‘misters’ – these women became known as ‘triple-companion misses’. Once exclusively catering for international and Hong Kong businessmen, these establish­ ments gradually opened for locals and led to services catering to men’s pleasure, including strip dancing, body massage and paid sex. Guangdong has had no difficulties in finding women to work in the sex trade; it has attracted a huge number of rural women from all over China to work in poorly paid assembly lines in the Pearl River Delta area or in service sectors in other parts of Guangdong. In the late 1990s, 10 million workers had migrated to Guangdong; by 2008 the number had climbed up to 20 million. Nearly half of these migrants were rural women and the majority of these women were of child-bearing age. Some turned to the sex trade for a combination of reasons, including joblessness, inadequate work skills, gender discrimination, failed marriage, domestic violence, financial troubles and the lack of protection of women’s rights. A vivid account of how migrant women desperate to make a living in Guangdong were attracted to a ‘red-light district’ in the Pearl River Delta region has been written by Pan Suiming. A sociologist at the Chinese People’s University in Beijing, Pan went to Guangdong to conduct field research on sex work in the late 1990s (Pan, 2000). Pan’s research in Guangdong trail-blazed a series of socio­ logical and anthropological studies on the sex trade and its

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connections to female migrant workers in other parts of China. For example, in 2003 Xia Guomei at the Shanghai Academy of Social Sciences conducted a survey of more than 5,400 respondents in eight rural counties in a southwestern province. These respondents included 1,620 rural residents of both genders who had worked in urban areas or still had urban jobs when interviewed. She found that there was a marked difference in self-reported sexual behaviours between men and women who left their rural homes for urban jobs and those who did not. In a period of three months before their recruitment into her survey study, nearly a quarter of the female migrant workers she studied had engaged in commercial sex (Xia Guomei & Yang Xiushi, 2006). The most vulnerable women in the sex trade at risk of exposure to HIV seem to be those ‘older’ sex workers. Why should it be that older sex workers are more susceptible to HIV? We could talk about the effect of accumulation, which means that older prostitutes may have been in the sex trade longer than younger prostitutes and therefore the probability of contracting an STI or HIV would be greater. In addition, a number of them may have contracted the virus in the past and have been diagnosed only recently. But there are other explanations for the greater vulnerability of older prostitutes. To begin with, older sex workers in China tend to come from the urban and rural poor who have dependent children. They need f lexible work hours and places near where they live to

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perform sexual services. Since the sex trade caters to clients who reject women on account of their age and diminished attractiveness, these older women are more likely to accept sex at a lower price and with greater risk than younger prostitutes. They work in dangerous places such as backstreets, riverbanks and deserted parks. Parking lots under long bridges, construction sites and small massage parlours are favoured sites as well. While these places do not draw police attention, personal safety is at risk at the same time. And eager to earn money for sex, older prostitutes rarely try very hard to persuade their clients to use condoms, if the clients do not want to do so. Take the city of Chengdu in Sichuan for example. In 2000, the lowest price for one act of sexual intercourse was 200 RMB. It went down to 100 RMB in 2005, and by 2008 it had dropped to 30 RMB. A ‘quick meal’, which means ejaculation within five minutes without using a condom, would cut the price to 15 RMB. At night, sex workers at this lowest end of the money-for-f lesh exchange tried to find customers along the banks of the river that cuts through the city. It was exactly at places like this where older prostitutes met their customers, who tended to be the city’s low-income earners and migrant workers.

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The emerging problem of HIV among Chinese gay men In the history of the HIV pandemic, the first wave of HIV in developed countries such as the United States and the United Kingdom disproportionately affected sexually active gay men. So from the start, gay communities in these countries were at the centre of attention from NGOs, community organisations and heath professionals for HIV prevention. In China, the response to HIV has been quite different. China’s initial HIV prevention efforts were launched in the late 1990s and the early 2000s by public health workers. They consistently targeted injecting drug users and female sex workers. When the connections between HIV and the blood trade in central China were exposed in the news media in the early 2000s, paid blood and plasma donors became another target group. HIV prevention among Chinese gay men, however, progressed slowly, largely because pilot studies showed a rather low prevalence of HIV among gay men. In 2004, for example, the HIV prevalence among gay men in China was officially estimated to be only 1.35 per cent. While the problem caught the attention of Chinese health officials, it did not cause too much concern. After all, HIV infections traced to male homosexuality did not loom large in the country’s accumulation of confirmed HIV cases over time or in its annually discovered HIV infections.

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But by 2008, various studies suggested that the HIV problem among gay men in China had become quite serious. By the end of 2009, the gravity of this problem was beyond any doubt, because 32.5 per cent of the 48,000 new HIV infections found in China in 2009 were traced to gay men. This discovery prompted Chinese health authorities to target the gay communities as a new priority for HIV prevention. HIV prevention among Chinese gay men is faced with several obstacles. For a start, Chinese society has long viewed sex between men with disapproval. This view has forced Chinese male homosexuals to hide their sexuality. Many are under societal or family pressures to marry women while continuing secret sexual relationships with men. Set against the background of stigma and pressures to conform to societal norms, clandestine and high-risk sex, as well as the reluctance to practise safer sex with their wives or other female partners, creates fertile ground for the spread of HIV and other STIs. Complicating the situation even more is the relatively new phenomenon of ‘money boys’ in China. These are homosexual, bisexual or heterosexual men who regularly have sex with men and occasionally with women in return for money. Even the term ‘money boys’, frequently shortened to ‘MB’ in Chinese gay communities, has become popular only in the last five to six years. Two recent studies of ‘money boys’ in China should be mentioned here. The first is a health survey of 484 MB in Chengdu, Nanjing and Shenyang. One published version of

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HIV IN CHINA

this study contains some interesting findings (Wang, Jiang & Ge et al., 2009). The MB provided sexual services to both male and female clients, although homosexual men were their regular and common customers. Most of the ‘money boys’ were in their early 20s. Seventy-five per cent of all the ‘money boys’, identified themselves as homosexuals. More than one-third did not know how to use condoms correctly, while 60 per cent of all the MB interviewed had engaged in anal penetration with men, or vaginal penetration with women. Nearly two-thirds consistently used condoms in sex with men. But 41 per cent failed to use condoms in sex with women. Finally, nearly 20 per cent of all the respondents in this study had STIs. And a quarter of the 484 respondents failed a HIV-related knowledge test (Cao, Jiang & Ge et al., 2009:583–585). Another study of ‘money boys’ was carried out by Liu Hongjie, a Chinese health researcher based in the US. In a recent publication, he suggests that MB appear to be a core HIV transmitter group among gay men and the general population in China because of their multiple sexual contacts with male and female partners. He bases his conclusion on his research into 351 men (some of whom were MB and others who were not) in the city of Shenzhen. Liu found that 54 per cent of the ‘money boys’ had had anal sex with six or more partners in the past six months, compared with 22 per cent of those who were not ‘money boys’. During the same period, 43 per cent had female sex partners, compared with only 26 per

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AN OVERVIEW OF CHINA’S HIV EPIDEMIC

cent of homosexual men who were not MB.  Only nine per cent of the ‘money boys’ had partners who insisted on condom use, and fewer than 30 per cent of all the men in the study had sex partners who encouraged condom use (see Liu & Liu, et al., 2009: 652–662). The two studies on ‘money boys’ offer no definite conclusion that ties these men to the spread of HIV in China’s gay communities. Furthermore, these studies are primarily concerned with risk behaviours, and do not take into account the social contexts and social relations of such risk behaviours. But this problem is hardly the fault of those public health researchers who conducted the two studies we have mentioned above. After all, the seriousness of HIV among gay men in China became evident only recently. The history of the ‘money boy’ phenomenon is relatively short in China. We are confident, however, that solid social research on commercial sex in Chinese gay communities will be available in the near future, since the problem has generated enough interest in the Chinese academic community at large and the Chinese social science community in particular.

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References Anagnost, Ann (2006), ‘Strange Circulations: The Blood Economy in Rural China,’ Economy and Society, vol. 35, no. 4, pp. 509–529. Erwin, Kathleen (2006), ‘The Circulatory System: Blood Procurement, AIDS, and the Social Body in China,’ Medical Anthropology Quarterly, New Series, vol. 20, no. 2, pp. 139–159. Gao, Yaojie (2005), AIDS Investigation in China (Zhongguo aizibing diaocha), Guangxi Normal University Press. Gill, Bates & Song, Gang (2006), ‘HIV/AIDS in Xinjiang: A Growing Regional Challenge’, China and Eurasia Forum Quarterly, vol. 4, no. 3, pp. 35–50. Global Fund China Office (2003), ‘Round-3 Proposal from China.’ He, Aifang (2001), ‘AIDS Ravages Central China’ (Aizibing zai zhongyuan dadi zinue), at , accessed on 21 January 2010. Hou, Yuangao (2009), The Price of Development: A Collection of Research Papers on the Harm of Illicit Drugs and HIV in Areas of Ethnic Minorities in West China (Fazhan de daijia – xibu shaoshu minzu dubin de shanghai he aizibing wenti), Beijing: Publishing House of the Central University of Ethnic Nationalities. Huang, Yingying (2004), ‘HIV/AIDS Risk among Brothel-Based Female Sex Workers in China,’ Sexually Transmitted Diseases, vol. 31, no. 11, pp. 695–700. Hyde, Sandra (2007), Eating Spring Rice: The Cultural Politics of AIDS in Southwest China, Berkeley: University of California Press. Jing, Jun (2005), ‘China’s HIV Surveillance’ (Zhongguo aizibing yiqing jiance zhuang kuang), Chinese Journal of AIDS & STD (Zhongguo aizibing xingbing), vol. 11, no. 6, pp. 446–448. Jing, Jun (2006), ‘A Prediction by Titmuss’ (Tiemosi yuyan), Open Times (Kaifang shidai), no. 6, pp. 71–88.

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Jing, Jun, Zhao, Hongxin, Lu, Yu, Tang, Lixia (2002), ‘AIDS and China’s Poverty Reduction’ (‘Aizibing yu Zhongguo Fupin Gongzuo’), in Jin Wei ed., Textbook on AIDS Policy for Chinese Cadres (Aizibing fangzhi ganbu zhengce duben), Beijing: Publications of Central Party School (Zhonggong zhongyang dangxiao chubanshe), pp. 226–241. Liu, Hongjie & Liu, Hui et.al. (2009), ‘Money Boys, HIV Risks, and the Associations between Norms and Safer Sex: A Respondent-Driven Sampling Study in Shenzhen, China,’ AIDS and Behavior, vol. 13, no. 4, pp. 652–662. Liu, Shao-hua (2007), The Menace of the Market: Migrant Youth, Heroin and AIDS in Rural Southwest China. Ph.D. dissertation, Columbia University. Lu, Lin et al. (2008), ‘The Changing Face of HIV in China,’ Nature, vol. 455, no. 7213, pp. 609–611. Ma, Lianying (1999), ‘Investigation into the Problems of Drug Abuse and Drug Trafficking in the Yi Areas of Liangshan’ (Dui Liangshan yiqu xifandu wenti de xianzhuang diaocha), Journal of Southwest Institute for Ethnic Groups (Xinan minzu xueyuan xuebao), vol. 20, supplement, pp. 316–318. Ministry of Health, UNAIDS and WHO (2006) Update on HIV/AIDS Epidemic and Response in China, Beijing, China. This update is a review of the situation in 2005. Pan, Suiming (2000), Survival and Experience: Tracking a Clandestine Red Light District (Shengcun yu tiyan – dui yige dixia hongdengqu de zhuizong diaocha), Beijing: China Social Science Press. Shao, Jing (2006), ‘Fluid Labor and Blood Money: The Economy of HIV/AIDS in Rural Central China,’ Cultural Anthropology, vol. 21, no. 4, pp. 535–569. State Council AIDS Working Committee Office (2007), A Joint Assessment of HIV/AIDS Prevention, Treatment, and Care in China, Beijing, China. Wan, Yanhai (2003), ‘AIDS in Henan and the Epidemic’s Impact’ (Henan aizibing liuxing he yingxiang), at , accessed on 21 January 2010.

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Wang, Jinling (2003), ‘Ethnicity, Class, and Gender: A Case Study on Sex Workers of the Yi Nationality in China’ (Minzu jieji he xingbie yuedu – zhongguong dalu yizu shangye xing gongzuozhe ge an yanjiu), Li Xiaojiang ed., Studies on Women and Gender Issues in China (Funu yu shehui xingbie yanjiu zai zhongguo), Tianjin: Tianjin People’s Publishing House, pp. 97–121. Wang, Ningxiao, Jiang, Juan & Ge, Fengqin (2009), ‘Study on Sexual Safety among MSM Sex Workers’ (Nan nan xing xingwei gongzuozhe de xing anquan xingwei diaocha), Chinese Journal of AIDS and STD (Zhongguo aizibing xingbing), vol. 15, no. 6, pp. 583–585. Wang, Tao (2008), ‘Applications of Census Method for Estimating the Population Size of Commercial Sex Workers in a Given City’ (yingyong puchafa guji moshi anchang jishu de yanjiu), Chinese Journal of Disease Control and Prevention (Zhong hua jibing kongzhi zazhi), vol. 12, no. 6, pp. 541–543. Weng, Naiqun (2004), ‘The Flow of Heroin, Sex, Blood and Its Products and the Transmission of Venereal Diseases and AIDS’ (Hailuoyin, xing, xueye jiqi zhipin de liudong yu aizibing xingbi de chuanbo), EthnoNational Studies (Minzuxue yanjiu), no. 6, pp. 40–49. Xia, Guomei & Yang, Xiushi (2006), ‘Research on Gender, Migration and the Risk of HIV/AIDS’ (Shehui xingbie, renkou liudong yu aizibing fengxian), Social Sciences in China (Zhongguo shehui kexue), no. 6, pp. 88–99. Yu, Xin (2000), ‘HIV/AIDS and Mental Health Issues’ (HIV/AIDS xiangguan de jingshen weisheng wenti), Chinese Mental Health Journal (Zhongguo jingshen weisheng zazhi), vol. 14, no. 4, pp. 247–250. Zhang, Ke (2005), ‘Report of Five Years of Investigation on AIDS in Henan (Henan aizibing wunian diaocha baogao), available at , accessed on 21 January 2010. Zhang, Yuping (2005), ‘HIV/AIDS Prevention among Chinese Minorities’ (shaoshu minzu fangzhi aizibing de sikao), Journal of Guangxi University for Nationalities (Guangxi minzu xuueyuan xuebao), vol. 27, no. 2, pp. 32–36.

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Zhuang, Kongshao (2005), ‘Revelation of the Tiger’s Day Initiative in the Yi Ethnic Region of Xiaoliangshan (Xiaoliangshan yizu huri minjian jiedu xingdong he renleixue de shijian), Journal of Guangxi University for Nationalities (Guangxi minzu xuueyuan xuebao), vol. 27, no. 2, pp. 38–47.

Notes 1 China’s lack of an effective response to HIV prior to the end of 2003 was the topic of several academic articles. See e.g. Gill, B. Chang, J. & Palmer, S. (2002), ‘China’s HIV Crisis’, Foreign Affairs, vol. 81, no. 2, 96–110. Kaufman, J. & Jing, J. (2002), China’s AIDS Crisis. The time to act is now, Science, 296; 5577, 2331–4. 2 For a systematic review on the HIV epidemic among China’s ethnic minorities, see Zhang Yuping, 2005. 3 The estimate made by Guangdong health officials was based on a series of studies that used a watered-down census-taking method to estimate the populations of female sex workers in several cities in Guangdong. For example, a study by the Centres for Disease Control in the city of Zhongshan in Guangdong relied on randomly selected sites of sex work from each district within the city, and it found 18,700 female sex workers in Zhongshan, which has a population of 2.5 million (see Wang Tao, 2008).

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★

2 Female Sex Workers in China: Their occupational concerns Huang Yingying

W

ith a long and complex history, sex work in China can be traced back more than 2000 years (Wang, 1988). Although it was banned after the founding of the People’s Republic in 1949, prostitution re-emerged in the late 1980s as China took a further step towards economic reforms and marketisation (Beijing Public Security Bureau, 1998). Illegal, stigmatised and constantly under attack from police, prostitution remains a full-time job for many Chinese women. Although there is no official estimation of the number of female sex workers,1 UNAIDS estimated that in 2005 there were already 127,000 sex workers and their clients living with HIV in China (UNAIDS, 2005). Just as in the twentieth century when the hierarchy of prostitution in China ranged from high-end courtesans, to employees in f lower-smoke rooms (brothels) (Hershatter, 1997), a great diversity of sex work exists in contemporary China. There are at least seven categories of Chinese sex workers - differentiated by workplace, the types of services that they offer, their income levels, the ways in which they work and live, and their demographic characteristics (Pan, 1997; Huang et.al., 2004). To this list must be added the relatively recent phenomenon of using the internet to engage in sex work.2

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This chapter focuses on falang xiaojie, which literally means ‘hair-salon girls’. But the term, broadly defined, refers to sex workers not only in brothels set up like simple hair salons but also sites of sex work disguised as ordinary bars, small massage parlours, low-cost karaoke halls and common bathhouses. At these places, sexual services are either provided on the spot or negotiated to take place elsewhere. In terms of their earnings, the sex workers associated with these prostitution locales are at the lower end of the Chinese sex industry. In contrast to female escorts who work at high-class hotels or more established brothels, the ‘hair-salon girls’ are at a greater risk of acquiring sexually transmitted infections (STIs) and HIV. They also face many more problems of personal safety such as physical violence against them by clients, thugs and even police. Only streetwalkers in China occupy a lower position than the hairsalon girls in terms of incomes and personal safety. The primary reason I will focus on the hair-salon girls is that the country’s HIV-prevention strategy has targeted these women as a most-at-risk population, along with streetwalkers, injecting drug users, men who have sex with men, commercial blood donors, and those with STIs.3 The hair-salon girls are perceived as needing urgent HIV awareness so they will begin to use condoms to prevent them acquiring HIV or infecting their clients if they already have the virus.4 But this strategy has yet to abandon the simplistic assumption that knowledge of HIV risks would lead to dramatic behavioural change among

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at-risk groups. Therefore, the correlations of knowledge and behavioural change have remained the yardstick for measuring the efficacy of health education programs among these women. However, I argue that HIV prevention must engage with the fact that sex workers have more urgent concerns than HIV in their everyday life. In addition to making money, they are afraid they will get pregnant or become infertile. They also fear that their relatives and friends will discover that they work in the sex industry. Their other fears include physical violence from thugs or police and exploitation by their handlers. If these other significant concerns are not addressed, HIV prevention is like a castle built on sand. In other words, an effective strategy for HIV prevention among Chinese sex workers must address the issue of HIV infection as part of myriad other issues that constitute what is really at stake for these women. We must address the social situations of everyday life of these sex workers, understand the contexts under which they work and the different degrees of agency they have and integrate this understanding into HIV prevention. Otherwise, health knowledge alone will not be sufficient to change risky sexual behaviour. A series of ethnographic studies was conducted from 1996 to 2008 by a team of researchers at Renmin University of China (the People’s University of China).5 My argument is based on these findings. I took part in most of these studies, which covered 15 red-light districts in ten Chinese cities. In total, we interviewed more than 1,000 female sex workers and

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about 200 male clients and brothel managers. At each location, my colleagues and I lived in hotels or rented rooms near the sex work sites, gradually integrating ourselves into the local scene. Gifts or meals for respondents were provided as compensation for their time. The topics we covered in the interviews were diverse, ranging from these women’s self-identity, their sexuality, and their work to their interactions with other sex workers, their handlers and their clients. We also examined how these women perceived the risks of HIV and more general health problems. In addition, we asked our respondents to describe what their lives were like and their experience of job mobility before they became sex workers. To protect the privacy of some of these women, I have changed their personal names and withheld details of where they lived and worked specifically.

Top concerns among female sex workers The sex workers we interviewed ranged in age from 16 to 45, all worked in brothels disguised as down-market hair salons, karaoke bars, massage parlours and bathhouses. Most were in their early 20s, unmarried, and had left school after nine years of education or earlier. The majority engaged in paid sexual intercourse; a few provided only hand-jobs or escort services

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that did not involve vaginal or anal penetration. In some of the settings we studied, especially at those brothels known as ‘bathing centres’, more diverse sexual services were available. The price for one act of vaginal intercourse at all of these settings ranged from 20 to 200 RMB, the equivalent of around three to 30 US dollars, depending on the f luctuations of the economy at the time. The majority of the women we interviewed were from rural areas, often a long way from their home towns, so they could avoid meeting people who might know them. However, in northeast China, where industrial workers were laid off in significant numbers in the late 1990s and early 2000s, most of the 104 women we interviewed there in 2002 were urbanites. Half had been laid off from stateowned enterprises. Unlike the rural women we studied elsewhere, these urban women worked as sex workers within their home towns or close to where they lived, an indication of their desperation after losing what they once considered to be a protected way of life in state-owned enterprises. Physical abuse was one of the top concerns among the respondents. In two of the red-light districts we studied, we found a few women who were forced into prostitution and worked in confined environments where they had lost their personal freedom and were subject to regular violence of various sorts. Their attempts to escape often met with beatings by pimps. However, blatant coercion was not common. How­ ever, even those women who entered sex work voluntarily

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were terrified of violence, although this fear came from a different source. One woman had this to say in an interview: ‘You’d better be careful and keep your eyes open. Sometimes policemen in plainclothes wander on the street. If you mistakenly solicit them, you’ll be arrested and put onto a van. They’ll then take you to a dark room, awful, without food to eat.’ Other women cautioned that a young woman like me would easily be suspected by police of selling sex in the area where she worked. ‘Sometimes when we were just playing card games around the table, the police would come and ask for our temporary residence card,’ said the female manager of a small brothel. ‘If you don’t have it, you’d be taken away. If you argue with them, the police would slap your face. Sometimes, even if you have the residency card, they tear it up and then take you away.’ Another grave concern among these women was violence committed by clients and criminal gangs. In the interviews we conducted, we heard one story after another about how prostitutes were seriously wounded and even killed by customers or gangsters. There was a widespread reluctance among these sex workers to report the serious crimes since they were afraid of retribution. Unwanted pregnancy, abortion, venereal infections and sterility were some of their other serious concerns. Xiao Li, a respondent, told me of her desire to fall in love and start a family. She said ‘I’m fine with the job now. I want to make money. You know, that’s my goal, making money. But I’m

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afraid that if I do this too long, it will harm me physically. If I eventually find a man I really love and I want to have a baby with him, I might not be able to get pregnant.’ While abortions could be performed at government hospitals we learned that hair-salon girls tended to seek abortions at small private clinics or substandard hospitals to save money. Sometimes, they did so because they relied on advice from their co-workers who had aborted in such places. In addition, they were also afraid of the questions they might face from doctors at government clinics or hospitals. Although they could lie, they still hesitated to use such facilities. To avoid STIs it was common among our respondents to use condoms whenever possible. They frequently douched their vaginas after sex and had monthly antibiotic injections to avoid inf lammation; some used enemas to avoid STIs.6 Having an STI would be extremely bad for their business, they said, and it must be kept secret at work. One of our interviewees put it this way: ‘I used to be infected, but I got cured. Don’t tell the others, especially don’t let Sister Yang [her pimp] know about this. Otherwise, they might get rid of me. If you have a disease, you can’t work for several days and can’t make money. The clients will beat you if they find out you have a disease and they’ll tell the manager.’ The women we interviewed were also terribly afraid that their families or friends back home might find out that they were sex workers. Concealing the nature of their profession

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from these families and friends involved different strategies such as using a false name, telling the folks back home that they worked nightshifts at a hospital or in a factory, not wiring too much money back home, and asking men to pretend to be their boyfriend. Almost all the sex workers we met could justify why they had started and stayed in the sex industry. These include poverty, abduction into prostitution, earning and saving money for a better life, and acquiring social contacts for personal advancement in the future. A number of women spoke of gaining personal freedom. For these women, prostitution was a better way of life than the one they had. Some of them also made a clear distinction between selling sex and selling souls. For example, one girl said that selling sex was her personal choice but she constantly reminded herself that she should never be ‘too coquettish’ at work. Excessive coquettishness at work, characterised by our respondents as a woman’s eagerness to go beyond vaginal penetration by performing other sexual services for her clients, was a debasing act of giving up one’s soul merely for the purpose of making money. This attitude was widely shared among the sex workers we interviewed. In fact, when a woman was overtly coquettish, her co-workers would call her a slut behind her back. One example of this was performing oral sex on a client, which was regarded among many of the sex workers we met as something extremely dirty, disgusting and degrading.

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Knowledge and practices To survive in the sex trade, a woman must know how to stay healthy in addition to making money. She must know how to avoid pregnancy. This requires her to know how to use a condom and negotiate its use with men. And if she becomes pregnant or develops an STI, she must know where to find medical help. In that case, she must know how to lie to her pimps about her inability to show up at work. She must also know how to avoid confrontations with her clients that are likely to lead to verbal or physical violence against her. Furthermore, she must know how to avoid the police and, if she is caught by the police, whom to contact to get her released through bribery. The top priority at work, however, is to have a steady f low of clients. Three forms of solicitation were common in the red-light districts we studied: solicitation by the handlers of prostitutes, by the women themselves, and by the clients (Huang et.al., 2004). Solicitation by the handlers, who were often called ‘managers’, enabled the handlers to control the sex workers. It also helped reduce these women’s risk of being arrested. Police arrests could seriously endanger the operation of prostitution rings, if confessions could be extracted from prostitutes in police custody or on the spot. Thus, solicitation by the handlers was considered in the redlight district to be the most professional form of keeping a steady f low of clients.

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Many of the women talked about how they applied the knowledge they acquired about men in the course of their work to their trade. Some women told us that they used body language and faked orgasms to make clients ejaculate quickly. Other women pretended to be virgins so that clients might be more generous with their tips. We heard about many other tricks in the sex trade. For example, one of our key informants believed that men like a woman who has just entered the business because she is not only fresh and clean but also knows little about the old tricks of sex work. ‘One day, a businessman brought me to a hotel,’ she recalled. ‘When I went to the bathroom to take a bath, I pretended I had never been in nice hotels before and I asked him to teach me how to use the taps.’ She explained that she did this deliberately so her client would assume that she was ‘pure and innocent’. She added, ‘Men want women to depend on them. If you behave like a sexually experienced woman, they regard you as not so controllable or despise you.’ We also learned from our interviews and observations in these red-light districts that customers who tended to spend a lot of money for paid sex usually came from the corporate sector. Many Chinese businessmen, we learned, regard prostitution as an ingredient of the corporate culture since business deals are frequently made at ‘entertainment venues’. The sexual nature of these venues serves as an icebreaker in the formation of new partnerships between businessmen, and can

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.

also reinforce an existing partnership. These men become what they call ‘iron-cast brothers’ because they have secretly shared a publicly denounced sexual experience. The secrecy binds them together. Many businessmen also need sex workers for psychological reasons. Pressure at work can be temporarily released by loose behaviour, drinking strong liquor and bad language in the company of sex workers. They also need comfort from sex workers, even if such comfort usually comes from deliberately performed acts of tenderness and caring. For example, a few male clients said that their clients from the business sector preferred sweet and gentle sex workers who ‘know how to talk and comfort’. This preference is not exclusive to businessmen, as it applies to a wide spectrum of men who patronise prostitutes. But tenderness in this context is due to an unbalanced power relationship since the men pay for the sexual favours they receive. So when it comes to the use of condoms in sexual intercourse, the preferences of the male customers inevitably carry a lot of weight, although it is not impossible for sex workers to negotiate condom use. Physical attraction is no doubt very important in the sex industry, but many sex workers we interviewed believed that using one’s brain to make money was much more crucial than merely using one’s body. Thus they learned how to send erotic text messages to their clients, how to dress for different men, and how to cook delicious meals for their clients or handlers. Above all, they learned how to handle situations that may get

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them badly hurt. For example, an interviewee said that she had learned how to distinguish ordinary clients and gangsters by observing their facial expressions, language and manners. Some women tried to protect their co-workers by phoning them when they went to hotels with their clients. In return, their coworkers would often help them when they were involved in unsafe situations such as going out with an unfamiliar client to an unfamiliar hotel. Mutual help extended to ‘girl talks’ among these women about sex and health. In my opinion, the sex workers we met were much better informed about reproductive health and more skilled in condom use than women outside the sex trade. We found that they had taught themselves about health issues by reading books and watching videos, and they shared their knowledge about sex and sexual safety with one another while chatting and waiting for their clients. Often the advice they swap is very explicit. An example of this is how a woman can cleverly use her mouth to put a condom on a man’s penis when the man has drunk a little too much. Another is how to determine if a man is clean and healthy by observing his phys­ ical appearance and, if possible, his genitals. Brothel-based prostitutes can refuse to have sex with a man who appears to be unhealthy. Their handlers also encourage the women to stay healthy and uninfected, even if it is mostly for the sake of making money for the prostitution rings. But translating that knowledge of safe sex into practice very

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much depends on the way the particular sex trade is organised. In our research on the hair-salon girls we found three major ways in which sex work was organised: employment-based; housing-based; and coercion-based. Employment-based prosti­ tution (the sex workers didn’t live and work in the same place) was typically found at settings such as bars, nightclubs or karaoke TV (KTV) establishments where there were clearly defined rules to be observed. The handlers of the sex workers at these settings were as responsible as the sex workers for soliciting clients. Because of this, the power relationship between the handlers and the sex workers was subtle. The handlers had to please the sex workers by providing them with more incentives to work on holidays when the sex workers wanted to take a break. The sex workers had to please the handlers to get them clients when business was sluggish. This give-and-take relationship means that these sex workers at least had some bargaining power. If they did not like their handlers, they could switch to another place for work. And since they lived elsewhere, they had some autonomy in their personal life. Some women working at these establishments had the attitude that every client would be the same and welcomed. However, others were more selective, choosing their clients on the basis of their physical appearance or manners. One way to reject an unpleasant client was for a sex worker to say that she was menstruating. Another way was to simply turn her back to the client so he would ask for a replacement.

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By contrast, in housing-based employment sex workers live and work in the same place. Massage parlours were typical of this form of sex work. When women both worked and lived under the watchful eye of their handlers, they lost much of their personal freedom. But work at these sites was voluntary. A woman could always leave and find a job elsewhere. Coercion-based employment, on the other hand, is a slave-like arrangement of work and life. In addition to the requirement for the sex workers who had been forced into prostitution to both work and live at the same sites, their handlers used special measures to prevent these women from escaping. Set up as hair salons, massage parlours and karaoke bars, these sites of sex work were often controlled by the managers or pimps. The women working for these characters were allowed to venture out to shop for things they needed but they were followed by ‘bodyguards’, mostly young men employed by prostitution rings. At first, the employers of these women usually bought them some pretty clothes and told them that they could pay them back once they began earning some money. Their initiation into sex work was offering companionship to men by watching DVDs together or serving as their escorts. They would be pressured to have sex with men later. With little control over their life, these women were subjected to constant verbal abuse and physical violence. The different organisational mechanisms of these three forms of sex work affected the sexual safety, personal agency

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and power relationships of the sex workers. At the employmentbased settings, the sex workers at least could try to negotiate with their clients over the use of condoms. They could support one another by sharing information and making sure their coworkers were safe. They also could socialise after work. At the housing-based settings, the sex workers lost much of their personal freedom, but they could still leave for employment elsewhere if they were upset by employers who blatantly ignored their concerns for safety, health and financial gains. Their bargaining power was their freedom to quit their jobs. The women who could not protect themselves at all were those working at the coercion-based sites of employment. They were allowed to make money and yet the terms for them to do so were non-negotiable, strictly set by their employers and reinforced through violence. The coercion-based establishments were often found in less-developed areas, and the women working at these places were mostly from impoverished rural families. Although the public attitude towards women who work as prostitutes because of poverty has taken on a degree of sympathy in recent years, public discrimination against the socalled ‘fallen women’ remains widespread in China. Fears of identity exposure may help to explain why many of the women we interviewed said that they had been coerced into prostitution but did not dare to seek help. They preferred to find their own means to escape. I have so far argued for a greater appreciation of the

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complexities of sex work among the hair-salon girls in China. The core of my argument is that these women have greater and graver concerns than HIV in their everyday life. Understanding these concerns is important for HIV prevention, because effective HIV prevention requires a body of sociological knowledge about the different patterns of sex work in terms of the varying forms of solicitation, the diverse methods in the social organisation of sex work, and the complex power relations between sex workers, their handlers and their clients. It is so often assumed by health professionals engaged in HIV prevention in China – and in many other parts of the world for that matter – that knowledge of HIV risk will somehow lead to dramatic behavioural change. This is a mechanical rationalisation of the correlations between one’s knowledge of risks and one’s behavioural modification. In real life, and especially when it comes to collective knowledge and behaviours of high-risk groups in a given society, people’s awareness of risks may or may not lead to effective prevention of those risks because of the specific social contexts in which these groups of individuals find themselves.

Policy issues affecting sex workers In addition to the structural factors such as economic and employment situation, two official policies have a direct bearing on sex work in China. One is the prohibition of prostitution. The other is HIV prevention. The prohibition of prostitution is

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reinforced through China’s criminal law and the country’s administrative law of public security. Those who organise women to work as prostitutes are punishable under the criminal law, and the penalty is between five to ten years in jail. In serious cases, the penalty could be life imprisonment. Under the administrative law of public security, women who work as prostitutes can be detained for five to 15 days and fined between 500 to 5,000 RMB (AUD8–80). It used to be the case that Chinese police could detain and fine a sex worker on the basis of the mere evidence of a condom found in her purse or pocket. In 2001, the Ministry of Public Security issued an order to ban the practice of using condoms as legal evidence. However, the condom-as-evidence practice continued among police throughout the country and clashed with the state policy of HIV prevention. Large-scale promotions of condom use among sex workers began in the provinces of Yunnan and Sichuan in 2001, with the support of a China-UK joint program for HIV prevention. The program immediately encountered the rift between the police using the presence of condoms as evidence in cracking down on prostitutes, and the medical establishment’s attempt to engage in the social marketing of condoms among prostitutes. The police had the upper hand at first. In several incidents that were widely reported in the news media, local police arrested sex workers recruited by health agencies to serve as peer educators. Public health practitioners complained to higher

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authorities that when the local police harassed sex workers it caused prostitutes to go underground, making it more difficult for the country’s HIV policy to be implemented among one of the most-at-risk populations. A major breakthrough took place in 2004 when the provincial government of Yunnan ordered all local hotels to provide condoms in the guest rooms and told local police officers not to interfere with condom promotions among sex workers. Around the same time, the National Committee for HIV/AIDS Prevention and Treatment pressured the Ministry of Public Security to allow the nationwide promotion of condom use among sex workers. The medical establishment eventually got a boost when a State Regulation of HIV/AIDS Prevention and Treatment was issued by the central government in 2006, which stipulated that all hotels and ‘entertainment venues’ throughout the country should make condoms available for their guests. The term ‘entertainment venues’ is a thinly disguised reference to the usual sites of prostitution set up as karaoke clubs, bathhouses, hair salons and massage parlours. The state regulation on HIV prevention, however, does not change the legal status of sex work in China. The state policy on the prohibition of prostitution and the state policy on HIV prevention are implemented in parallel by different government agencies whose mandate forms a contrast with one another. What this means is that police crackdowns on prostitution and condom promotions among sex workers will co-exist in a

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contradictory relationship, unless prostitution is decriminalised. Arguments for legalising or decriminalising prostitution in China have been made repeatedly by various advocates over the past decade, but the proposals to do so have been restricted to academic discussions and online expressions of personal opinions. They have yet to become legislative proposals.7

References Beijing Public Security Bureau (1998), A Record on Brothel Shutdowns in Bejing (Beijing fengbi jiyuan ji shi), Beijing: China Peace Publishing House. Chen, X., Yin, Y., Liang, G., et al. (2005), ‘Sexually transmitted infections among female sex workers in Yunnan, China’, AIDS Patient Care and STDs, 19(12), pp. 853–860. Ding, Y., Detels, R., Zhao, Z., et al. (2005), ‘HIV infection and sexually transmitted diseases in female commercial sex workers in China’, Journal of Acquired Immune Deficiency Syndrome, 38(3), pp. 314–319. Gill, B., (2006), Assessing HIV/AIDS Initiatives in China, Washington, DC: Center for Strategic and International Studies. Hershatter, G., (1997), Dangerous Pleasures: Prostitution and Modernity in Twentieth-Century Shanghai. Berkeley, CA: University of California Press. Hesketh, T., Zhang, J. & Qiang, D. (2005), ‘HIV knowledge and risk behavior of female sex workers in Yunnan province, China: Potential as bridging groups to the general population’, AIDS Care, 17(8), pp. 958–966. Huang, Y., (2004), ‘HIV/AIDS Risk among Brothel-Based Female Sex Workers in China: Assessing the Terms, Content, and Knowledge of Sex Work,’ Sexually Transmitted Diseases, 31(11), pp. 695–700.

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Huang, Y., Henderson, G.E., Pan, S. & Cohen, M.S. (2004), ‘HIV/AIDS Risk Among Brothel- Based Female Sex Workers in China: Assessing the Terms, Content and Knowledge of Sex Work’, Sexually Transmitted Diseases, vol. 11, pp. 695–700. Lau, J., Tsui, H., Siah, P. & Zhang, K. (2002), ‘A study on female sex workers in southern China (shenzhen): HIV-related knowledge, condom use, and STD history’, AIDS Care, 14(2), pp. 219–233. Pan, Suiming (1997), Three Red Light Districts in South of China (Cunzai yu huangmiu). Guangzhou: Qunyan Publishing House. Pan, Suiming (2004), Chinese Sexual Behaviors and Relationships (Zhongguoren de xingxingwei yu xingguanxi), Beijing: Social Sciences Documentation Press. UNAIDS (2005), Update on the HIV/AIDS Epidemic and Response in China, available at , accessed on 6 December 2009. Wang, Shunu (1988), The History of Prostitution in China (Zhongguo changjishi) Beijing: Sanlian Publishing House.

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Notes 1 Different estimates of the number of female commercial sex workers in China have been made over the years. A think-tank in the US estimated in 2006 that China had 4 to 6 million female commercial sex workers (Gill, 2006). A sociologist and expert on the Chinese sex industry estimated in 2004 that China had 1.67 million to 6.15 million female commercial sex worker from 1980s to 2000 (Pan, 2004). In 2004 Chinese Public Security sources estimated that there were in the region of four to ten million sex workers in the country (Huang, 2004). 2 According to the China Network Information Center, there were 338 million internet users in China in 2009. 3 See Chinese State Council AIDS Working Committee Office and UN Theme Group on AIDS in China (2007), A joint assessment of HIV/AIDS prevention, treatment, and care in China, available at , accessed on 28 Dec. 2009. 4 Numerous studies have been conducted to identify the risky behaviours and STI situations among females sex workers (Ding, et al., 2005; Chen, et al., 2005; Hesketh, et. al., 2005; Lau, et al., 2002). 5 These studies, led by Professor Pan Suiming, were funded by the China-UK HIV/AIDS Prevention and Care Project, the Ziteng Organization, Oxfam, in Hong Kong, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. 6 These methods to avoid STIs are problematic, but they are widely used among female sex workers. 7 Debates about legalising prostitution in China tend to take place in cyberspace. Very different opinions have been voiced. Some are in favour of legalising prostitution for the exclusive purpose of regulating it and preventing the unnecessary spread of STIs. Others are for keeping the country’s anti-prostitution police in name and, at the same time, allowing prostitution to exist as a social reality.

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3 Drugs, HIV and Chinese Youth Jing Jun

O

n a hot day in mid-August 2003, I visited a detention centre in the city of Kunming in the southwestern province of Yunnan. It ran a detoxification program for more than 400 inmates, the majority of whom injected heroin. I was with four health specialists from Beijing to see if an HIV education program could be established there. We had learned that HIV prevalence in the centres for drug detoxification in Yunnan was as high as 30 per cent. After a brief conversation with the commanding officer, he took us to see some of the cells. There were no beds in these otherwise clean cells, only a dozen neatly arranged straw mats in each cell. As we chatted with the commanding officer, a whistle was blown and the inmates filed out of their cells into a yard. All sat on little wooden stools and began to recite, in perfect time, a memorised text about the dangers of drug consumption. Four inmates then staged a tear-jerking play in which a mother was seized by grief upon discovering that her only son was a heroin addict. As we watched the play, one of the police officers explained to me that it had been written by a former inmate and was routinely performed for new prisoners, family visitors or government inspectors. My attention was turned from the performance to the spectators in the first three rows of the

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audience because they looked very young. The officer whispered to me that those inmates were aged from 16 to 17. Older inmates were sitting behind these minors, said the officer, who added that he and his colleagues had little hope of rehabilitating older heroin addicts because they would shoot up as soon as they were released. And even most of the very young inmates, he said, would return to drugs sooner or later, as they would be drawn back into undesirable circles of friends after they had served their prison terms. The relapse rate for the inmates released from this particular prison in the previous year was as high as 95 per cent. I visited four more compulsory rehabilitation centres for drug users elsewhere in China. These research visits made me increasingly aware that peer relationships play a key role in drug use among the country’s young people. For example, some of the inmates who were released from the detention centre in Kunming participated in a Project for Drug Rehabilitation via Methadone Treatment in 2004.1 As an evaluator of the impact of this project, I interviewed its participants. One was a woman barely over thirty years of age. She told me that she had become a sex worker at 18 and quickly befriended a group of fellow sex workers from Guangdong province. These women taught her the tricks to survive in the sex industry. They were ‘like blood sisters to me’, she recalled. After she saw these friends of hers looking rather relaxed and falling peacefully to sleep under the spell of heroin, she felt that

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they were ‘in the realm of sheer pleasure,’ she said. A few days later, she obtained, with the help of these friends, a small parcel of heroin to use herself. After she had smoked heroin three times, she became addicted, she said, and later switched to injecting heroin.2 This woman also switched from irregular sex work to receiving at least one client a day so as to make the extra money to buy drugs. When she explained how she had been enrolled into the treatment program, she mentioned casually that her husband was living with HIV. It turned out that her husband, also a heroin addict, had shared needles with other users. Fortunately, she was not infected by HIV nor was her fouryear-old son. She explained that her husband had had other women as sexual partners, and therefore she consistently asked him to use a condom in sexual intercourse with her. She said that what most concerned her was the future of her son and that she wanted him to be adopted by a good family so he could be well fed and well educated. Talking about her son made her sad and tearful. She turned her eyes to two young researchers who took part in the interview. She murmured partly to me and mostly to herself: ‘See what a happy life they have. They will have a bright future.’

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Drugs, prisons and rehabilitation Illicit drugs in China, by official ruling, include marijuana, opium, cocaine, heroin and various synthetic drugs. At present, consumption of illicit drugs is found everywhere in China; not a single Chinese city is spared. But for a long time, narcotics and other illicit drugs simply could not be found in China after the government-led campaign against the production, trafficking and consumption of opium in the early 1950s. In the 1980s China opened up trade with its neighbours and subsequently became a transit route for Southeast Asian heroin bound for international drug markets. Consequently, the number of domestic drug users began to rise (Qian, 2006). At the beginning, however, only heroin from outside the Chinese borders and cannabis grown inside China were available for consumption. Then, synthetic drugs came into the picture in the early 1990s as well. Although synthetic drugs are now increasingly popular among young people in China, the country’s annual reports on illicit drug control over the last ten years repeatedly reveal that heroin has been the drug of choice. Authorities of the public security apparatus estimate that 90 per cent of the country’s drug users consumed heroin. Half the heroin users resort to injecting, and among these injecting drug users, more than 40 per cent share needles. Hence it is not hard to understand why Chinese heroin users who inject and share needles are vulnerable to HIV, hepatitis C and other blood-borne diseases. And it goes

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without saying that organised crimes associated with drug production and trafficking are considered a serious problem by the Chinese public and government officials. In dealing with illicit drugs, the Chinese government has established four institutional means of incarceration. The Ministry of Public Security at the central government runs a countrywide network of ‘compulsory detoxification centres’. At such places, drug users arrested by police for the first time are imprisoned to undergo rehabilitation by force. The length of incarceration in these police-run institutions is three to six months. The Ministry of Justice also runs a nationwide network of prisons for drug users, although these are known as ‘centres for drug rehabilitation through labour education’. The inmates in these labour camps are sentenced by the court system to one to three years when they are found to have repeated drug use. In the late 1990s, voluntary detoxification programs began to operate all over the country under the supervision of local police. Often persuaded by their families to seek help, drug users come to these centres and voluntarily submit to a way of life as if they are imprisoned. The three institutions I have mentioned all use a ‘cold-turkey’ approach in dealing with drug addiction and recovery. In other words, drug users are forced to give up injecting drugs at once, relying on their willpower to fight addiction. In addition, in 2003 the Chinese government introduced a methadone program that now operates nationwide and in

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which drug users enrol on a voluntary basis. The methadone program was established in direct response to the problem of HIV among injecting drug users. According to the Chinese government, 41 per cent of the country’s case load of HIV infections accumulated by late 2004 was caused by injecting drug use (State Council AIDS Working Committee Office, 2004:7).

Friends and drug use Every time I visited a prison or labour camp functioning as a drug rehabilitation facility, I felt depressed. In one prison, I saw a man gagged and chained by leather belts that were fastened to a heavy wooden bed. I was told that he had to be restrained because he attacked a police officer when he desperately needed heroin. In another prison, I learned about an outbreak of HIV in one block of cells because heroin was smuggled into these cells but there was only one syringe. One of the inmates who shared the syringe was HIV positive. In another prison, exclusively set up for women, I met ten young inmates who had been sex workers, and five of them said that they had entered prostitution to earn extra money to support their drug habit. But the most disheartening aspect of these institutions was the fact that many young people, male and female, were locked up in the cells instead of spending time at school or leading a

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productive life. In interview after interview, however, I found the young people to be approachable, understanding and even friendly. Yet, at some point in their young lives, they had taken a few missteps that had landed them in jail. I also learned that the most common way for a youngster to engage in drug use for the first time was through his or her peers: a schoolmate, a team mate from sports, a neighbourhood acquaintance, a genial partner in video games in an internet cafe, or a friendly coworker. The same circles of friends also played a key role for young addicts to resume drug use after their release from rehabilitation institutions. So, both initiation into injecting drug use and relapse are connected with what friends a youngster has made. To confirm what I had learned, I carefully examined three research reports. The first report was written by a group of researchers at Tsinghua University (AIDS Policy Research Center, 2005). It was based on interviews with 48 drug users in Yunnan province, and over half of these people said that their friends got them involved in drug use. The second was written by Li Zongtao (Li, 2006), who was a research associate at the AIDS Policy Research Center, Tsinghua University. She interviewed 30 drug users in Sichuan province, and 25 of these people said that their friends had introduced them to drug use. The third report was written by Ma Yongqing (Ma, 2006) on the basis of interviews with 65 drug addicts in Yunnan. Of these individuals, 45 said they had learned how to use drugs

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from their friends. In all, the overwhelming majority of the 143 drug users interviewed for these three studies were under the age of 35.3 While the friendship-induced initiation into the world of illicit drugs is a common denominator among these young addicts, the specific and particular reasons to use drugs for the first time varied a great deal. These included ‘feeling depressed after being fired’, ‘staying awake when keeping a vigil beside the coffin of my adoptive father’, ‘being tempted by fellow workers when making money as a prostitute’, ‘feeling depressed after being dumped by my girlfriend’, ‘winning in a gambling game and using the money to buy drugs for enjoyment with friends’, ‘trying drugs when playing with friends in a nightclub’, ‘getting some gratuity money from the underworld society for collecting debts and taking drugs with friends afterward’, ‘tempted by my first boyfriend’, ‘having nothing to do when being kept as a concubine and introduced by friends to try K-powder in a club’. Based on these self-reports, the general reasons for entering the world of drug use include social problems (unemployment, working in the sex industry and collecting debts for criminals), emotional problems (failure in love and depression associated with being a kept concubine to a married man) and physical problems ( recovering from fatigue and relieving stomachache). However, it is peer relationships that consistently connect these problems, leading to the first-time experience of drug

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use. Furthermore, research conducted by this author and other scholars demonstrates that peer relationships also play a key role in relapse – the reuse of illicit drugs after a period of incarcer­ ation or self-imposed abstinence (see Cao, 2005:8–17; Wang, 2003: 42–45). To explore in detail the role that peer relationships play in drug use among youth, we need to understand two background issues: the patterns of drug use in China, and the social profiles of drug users. As I stated earlier, drug use in post-revolutionary China began in the 1980s. Heroin (smoking or injecting) accounts for the vast majority of illicit drugs consumed in China. However, in 2000, China’s illicit drugs problems were complicated by the emergence of synthetic drugs. These drugs are easier to produce and their production sites are harder for police to find. Public security authorities believe that 11 per cent of drug users in the country now prefer synthetic drugs. In 2004, this figure was only 1.7 per cent. The entry points for these synthetic drugs include nightclubs, bars, discos, KTV lounges and hotels. In 2007, Chinese police in 20 cities said they had captured more synthetic drugs than heroin. Between 2001 and 2006, China’s methamphetamine seizures accounted for 27 per cent of the world’s total seizures by police. A substantial proportion of the methamphetamine seized in China is believed to have been manufactured in northern Myanmar, and by 2006 nearly all Chinese provinces had reported police seizures of methamphetamine tablets produced

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in Myanmar. In addition, lack of government regulations over procurements of precursor chemicals and the existence of many chemical plants in China explain, in part, why synthetic drugs have f looded the People’s Republic. Chinese drug users include both documented and undocumented users, which means that some of them are on police record while many are not. Documented drug users have received either compulsory rehabilitation run by public security agencies or rehabilitation through labour education run by judicial institutions. According to the National Narcotics Control Commission’s report for 1998, the country had only 50,000 documented drug users in 1988; the number increased to 70,000 by 1989 and to 148,000 by 1991. Thereafter, the number of documented drug users rose by more than 250,000 every five years. At the end of 2005, the number of documented drug users reached 1,180,000. Later editions of China Narcotics Control Report stopped revealing the number of documented drug users.4 But given the previous annual increases, it may now easily have reached 1.2 million. Drug users who have eluded public security agencies also need to be accounted for in our analysis. If a usual method of calculation is used, the ratio of documented drug users and those who are not should be within the range of 1:4 to 1:7. On the basis of this internationally used method, the total number of drug users in China will be between 4,720,000 and

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8,260,000 by the end of 2005. A team of researchers in China used several different methods to recalculate the ratio of drug users who are documented and those who are not. They did so in 2003 and found that the lower end of this ratio is 1:1.4 and the higher end is 1:3. Based on their method of calculation, the number of drug users in China, by 2005, is around 1,652,000 at the lower end and 3,540,000 at the higher end. Authorities in the Chinese public security system believe that the higherend estimate is closer to reality. Drug use, and especially drug use by injection, defined the early phase of China’s HIV epidemic. In 1989, a single HIV surveillance study found more than 100 HIV-positive individuals among injecting drug users in a small border town in Yunnan province. A deputy minister of health in China from 1995 to 2007 stated in an academic journal that injecting drug users in this small border town may have been the core source for all later sub-epidemics of HIV in China (Wang, 2007:3–7). If so, it seems that HIV moved rapidly along the routes of the drug trade because the virus was detected amongst injecting drug users in all Chinese provinces by 2002. And two years later, 41 per cent of HIV infections in China were estimated to be due to injecting drug use. But because of a zero-tolerance attitude, the Chinese government did not roll out large-scale needle exchange or methadone programs until 2004. By then, it became more than apparent to epidemiologists and health officials that injecting serves as a bridge for HIV to

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enter the general population since HIV-infected drug users have spouses or sexual partners who may be infected with HIV through sexual intercourse.

Learning from narratives of personal experience As for the social profiles of drug users in China, those aged 35 and below have made up more than 70 per cent of the total illicit drug-using population documented by the police between 2001 and 2005. We gather from the stories of the 143 drug users mentioned at the beginning of this chapter that most of them were under 35 years old and most started using drugs because their friends did. Other studies verify this finding. For example, Liu Zhimin (2000:123–125) and his colleagues investigated 657 drug users in Beijing, Harbin, Chongqing and Wuhan in 1998, and they discovered that 49.8 per cent of the respondents first took drugs under pressure from their friends, classmates and companions. Liao Longhui (2001:48–51) mentioned that initial drug use through friends, classmates and intimate acquaintances made up 61 per cent of his study’s sample population. A study by Wang Jun (2006:125–127) and his colleagues in the city of Urumqi found that 443 of the 509 addicts in the study had drug-abusing friends. And in a study of 324 drug users, Zhu Lin (2005:573–575) found that initial

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drug use was closely related to things that peers and friends do, including guiding the first-timers in learning how to inject drugs. In addition, various studies in Yunnan province have found that sharing drugs, and especially heroin, was a way to show courtesy and reciprocity among youth in some ethnic communities deeply involved in the illicit drug trade (see e.g., Zhuang, 2005:38–47). Now let’s examine the social contexts in which peers exert their inf luence. Outlined below are six cases of initial drug use from which we can extract the nuances of the social contexts in which youngsters take to drugs for the first time.5 These cases are personal stories of drug use which I have condensed here for the purpose of analysis. CASE 1: Xiao Chen, male, age 22, first took drugs when he was 15. His parents were too busy to ask about his activities, he said, and so he played online games whenever he had the opportunity. His academic performance soon began deteriorating. His parents became angry and scolded him repeatedly about his poor academic record. At that time, he met Liu who was two years older than him and whose parents were divorced. Liu befriended him and the two often went to internet bars together. Under Liu’s inf luence, Xiao Chen gradually began smoking cigarettes and drinking alcohol. He then started gambling and stealing. He eventually used drugs and became addicted. In

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order to get money for drugs, Xiao Chen first sold off his family’s electrical appliances and then engaged in extortion to make money to support his drug addiction. He had been in rehabilitation three times. CASE 2: Hou Zai, male, age 21, managed to finish high school but did not like to study. Hou Zai’s father was a government officer and his mother worked in a factory. While at school, he played hard and studied little. He often quarrelled with his parents who tried to make him study harder. He said that his father always used ‘a pile of lofty ideas’ to make him realise how important it was for him to be a good student. This led to more quarrels with his parents. His initiation into the world of illicit drugs was at a dance hall where he saw a few youngsters using drugs. He thought that they were very ‘cool’. Later, when he went to the club again, a friend of his gave him a ‘head-shaking capsule’ (Ecstasy). ‘I became very high after taking it,’ he recalled. CASE 3: Hai’er, female, age 17, an only child. She said that she ‘had no interest in learning’ and often skipped classes. She got acquainted with a circle of older friends who were out of work. These friends ‘just hang around all day’. One day she went to the home of one of these friends, and saw several women injecting ‘white powder’ (heroin). They persuaded her to try it. She was curious about ‘the intoxicated

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and joyful looks’ on their faces and tried to inject the heroin with their help. After the injection, she felt dizzy and began vomiting. Her friends told her that she would soon get used to it and persuaded her to try it again. She did, and she eventually became addicted. She dropped out of school and began to work in a marketplace. She used part of her salary to buy drugs. CASE 4: Li Qiang, male, age 20, began smoking and drinking in high school. He did not like academic studies and often skipped classes. He got to know some friends who frequently stayed in internet bars for the night. Later he was invited to drink with these friends and he saw one of them squatting on the ground, trying to heat up a tinfoil of heroin with a cigarette lighter. Another friend handed him a cigarette. He sensed that there was heroin in the cigarette. His friend said to the others that Li Qiang might not have the courage to smoke it. He did. ‘But it didn’t feel that special,’ he recalled. Yet, he later bought a heroinmixed cigarette through a friend of his, embarking on a journey of drug using. CASE 5: Zhang Pan, female, age 19, went through a traumatic experience when her parents divorced. She left school at 17 and became a sex worker in a nightclub, where she took up smoking and drinking. She had a boyfriend while working in the sex trade. One day when she visited him

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at his home, she found him restrained by an iron chain attached to his feet. His parents told her that he was craving heroin and that he had to be forced to quit. She immediately wanted to break up with him but he would not let her. To keep her as a companion, he cheated her into smoking tobacco mixed with heroin. CASE 6: Shao Hui, male, age 24, worked as a disc jockey in a nightclub. His mother was a school teacher, and his father was a police officer. His parents divorced when he was only six. His mother remarried, but he said he always felt uncomfortable living with his mother and his step-father. He had other jobs before becoming a DJ. He had also fallen in love with a young woman. When she dumped him for another man, he was heartbroken and depressed. He met Mao Mao, a heroin user, who told him that all his worries would disappear once he took heroin. In the nightclub where he worked, he tried heroin by inhaling it only five times before he vomited. Later, he smoked heroin again and again, and he said that he learned to enjoy the calmness that came from the white powder. ★

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From the cases above, we can see that the initial drug use for these young people was not accidental. Curiosity, impulse or ignorance were not good enough reasons for starting drug use. Similarly, temptation and deception were secondary reasons. Rocky family dynamics, deteriorating relationship between the parents, failures in inter-generational communication and falling academic performance had already combined to deal a blow to these young people before their initial use of drugs. Xiao Chen’s drug use at the age of 15 was partly due to the fact that his parents were too busy to take care of him. His academic performance declined drastically because he spent too much time playing video games online. What really made the difference, however, was his quarrel with his parents over his academic performance and his subsequent relationship with a stranger who not only became his friend but also introduced him to drugs. Hou Zai also often quarrelled with his parents because of his lack of interest in school. There also seems to be a failure of communication between he and his father, with his father tending to lecture him. And note that, instead of reacting with disapproval, his first reaction on seeing youngsters abusing drugs was that they were cool. In the cases of Hai’er and Li Qiang, the lack of interest in school was also the starting point of their rebellious behaviour which eventually ended up in their use of heroin. In addition to problems at school and with their parents, we should take note of workplaces, sites of recreation, lifestyles, perceived images of self, and peer pressure

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among these young people. For example, Zhang Pan became a sex worker at 17. She worked in a nightclub attached to the sex industry. In this social space, the presence of illicit drugs should not be considered surprising. And in the case of Shao Hui, although he vomited after taking drugs for the first time, he gradually became addicted. His addiction must be understood in the context of his experience of working in a nightclub as a disc jockey, his depression after his failed love affair, and the shadow of his parents’ divorce over his life.

Relapses Let’s now examine the problem of relapse among youth when they are released from rehabilitation centres. In the summer of 2005, I studied two methadone clinics in south China, one located in Gejiu, Yunnan province, and the other in Leshan, Sichuan province. In this study, I met 48 young men and women who were trying to stop using drugs. Almost all of them thought that they could withdraw from drugs and return to normal life with the government’s help. What they meant was that they badly needed a tightly supervised way of life so that they would not be tempted by friends who continued to use drugs. In the process of the interviews, I heard story after story in which young people began to use drugs as soon as they lost this supervision, be it a prison, a police-monitored clinic, or a neighbourhood-watch-like situation. To further

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explore the role of peers in relapse, I will examine four cases of relapse. CASE 7: Mao Ke, male, age 37, started taking drugs at the age of 23. In the early 1990s, one of Mao Ke’s cousins forged receipts to swindle a department store. The forged receipts needed a government seal on them. The cousin came to Mao Ke for help because he was a good calligrapher who could carve seals. He carved a wooden seal and made the receipts look genuine. But police caught the two men. Mao received a one-year prison sentence with probation. He was fired from his job immediately. At this difficult time of his life, he met a warm-hearted friend nicknamed Little Pidan, who took him to a KTV club for fun. Little Pidan called four of his own friends over and one of them brought heroin into the club. The six began injecting the heroin by using a method called ‘chasing the dragon’, meaning that blood would be drawn from a vein, pushed back into it, and then drawn into the syringe before injection. It was the first time that Mao Ke used heroin. A year later, his heroin use was discovered by his parents who sent him for rehabilitation. When he was released, his mother bought him new clothes and shoes because she thought the new clothes would bring him good luck. Once free and wearing his new clothes, he attended a dinner arranged by Little Pidan. As a gesture of brotherhood, he said, whoever came out of a police-managed rehabilitation

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institution must be treated to a dinner first and drugs second. Sometimes the dinner was omitted but heroin was an essential part of the reunion. That night, he injected heroin as soon as it was presented to him. CASE 8: An Liming, male, age 24, was tempted back to heroin by friends. As soon as he got out of the rehabilitation centre, his friends offered him heroin as a sign of brotherhood. He said that he could not resist the offer because he felt lonely and needed friends around him. To make money to support himself, he started dealing drugs. He soon met Little Shen. It was through heroin that the two young people got to know each other. One day, An Liming was going to buy drugs, but he couldn’t withdraw any money from an ATM with his bankcard. Little Shen was drinking tea with a friend nearby. She saw from his pale face that he was suffering from a craving for drugs, and she rushed to get a dosage of ‘white powder’ for him. They became instant friends. When Little Shen left for Shanghai to work as a sex worker again, he gave her three grams of heroin as a farewell gift. CASE 9: Wu Taotao, male, age 22, was forced back into injecting heroin. He was feeling frustrated by a difficult relationship with his girlfriend when he met two of his ex-classmates who took him to a teahouse to chat. After a while, they took out some white

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powder. They said that this drug made them feel like they were f loating along a river and that all their worries went away. He was persuaded to try it, but he felt sick instead of feeling well, he said. And yet, he did not give up. He tried to smoke heroin again and again until he also felt like f loating on a river. One year later, he was injecting heroin twice a day and the expense of his drug use was beyond his means. So he stopped taking heroin. Unfortunately, he met the two ex-classmates again. They bitterly complained that he must have reported them to the police, causing them a stint in jail. He protested that he was not a snitch. His former classmates then said that he had to prove it by taking heroin. When he refused, they held him up and forcibly injected heroin into his arm. CASE 10: Lan Lan, female, age 30, was tempted to take drugs by two of her friends. She refused at first, but her friends made her believe that she could not be counted as a true friend if she continued to refuse. She gradually became addicted through repeated consumption of heroin. Being short of money for heroin, she began to trade sexual favours for cash and ended up in jail for prostitution. After her release from prison, she vowed that she would never touch drugs or do sex work again. But those previous friends of hers mocked her. ‘I didn’t want to lose face in front of my friends, and so I began doing drugs again.’

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★ In the cases of Mao Ke and An Liming returning to drug use was almost inescapable. After release from rehabilitation centres, they were immediately connected with their previous friends. The return to drugs symbolised the regaining of personal freedom in the case of Mao Ke, while for An Liming it was a gesture of brotherhood. As for Wu Taotao, friendship turned ugly, since he was suspected of having broken a subculture’s code of honour. The experience of Lan Lan demonstrates the close relationship for women between drug use and commercial sex work. After all, sex work is a way of making extra money to sustain one’s drug addiction. But in the case of her relapse, it was her longing for respect that led her back to drug use. These personal stories show how easy it is to get illicit drugs in China. In nightclubs, internet bars, KTV establish­ ments, back streets and even residential buildings, drugs can be obtained through resourceful friends. I have estimated on the basis of the annual reports issued by the National Narcotics Control Commission in China that the average amount of heroin in circulation in the People’s Republic was 175 metric tons per year between 1999 and 2005. But it is not entirely the availability of illicit drugs that is at fault. Two major social forces are at play here. The first is the social marginalisation of many young people either because they are unemployed urban youth or because they are young people from rural areas who

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have migrated to cities but cannot find jobs. The second is the intriguing effect of social stratification in the Chinese education system, which turns many young people in urban areas into an underclass once they fail in the race to get a college education.6 Both social forces lead to the creation of a youth subculture in which deviant behaviour is celebrated. Marginalisation associated with unemployment is not very hard to understand. This is why when the number of drug users on police record exceeded the one-million mark in China during 2003, the Chinese government admitted that the rise in use of illicit drugs might have a lot to do with socioeconomics. Of all the documented drug users that year, the government revealed, 54.57 per cent were unemployed and 28 per cent were from a rural background. This revelation points to three things. First, unemployment was a common denominator for more than half of the documented drug users. Second, nearly one-third of these people originated in the Chinese countryside which was experiencing a huge out-migration of young people for jobs in urban settings. And third, we can safely assume that most of those documented drug users who were from a rural background had moved into cities and could not find jobs. And we should also note that unemployment in urban settings leads to very different poverty from that in rural settings. Urban poverty that affects both urbanites and migrant workers is a consistent characteristic of young drug users in China. By

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comparison, it is much harder to explain why China’s education system has a lot to do with illicit drug use among young people. Let’s focus on the education system’s function in social stratification and its contribution to the creation of a subculture of deviant youngsters.

Youth, academic failure and the creation of deviance That education systems in different cultures and societies have a function of social stratification is nothing new. In varying degrees, all education systems help some students to climb up the socioeconomic ladder while sending others to the bottom. One key factor of the two outcomes is academic performance. Another key factor is that schools are stratified in terms of their reputation, management skills, quality of instruction, admission policy and financial resources. The Chinese education system is no exception, but it is distinguished for its highly competitive, exam-driven environment. Furthermore, higher education in China has changed, within a short period of time, from an incubator of elites to a mass producer of academic degrees. In the early 1980s, no more than 10 per cent of graduates from all high schools in China went to university. Now, this has risen to 50 per cent. So, today, if you don’t have a college degree, you are automatically relegated to the country’s underclass and this

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is because the minimum requirement for a good job, and certainly the most-vied-for government jobs, is a university degree. Every schoolchild and every parent who has a child in school recognises and appreciates the importance of an academic degree. Previously the overwhelming majority of graduates from high schools did not go to college but still managed to find decent jobs, whereas nowadays the failure to attend college is a great matter of shame for the students. Vanessa Fong, an American-Chinese anthropologist, has written of the tremendous pressures to succeed in schools in mainland China on the basis of her ethnographic research in a city of northeast China. She noted that the students and their parents she studied live in third-world conditions but have firstworld dreams which must be translated into good school grades, for without these they cannot realise their dreams. Failure at school means deep shame, not only for the students but also for the parents and even grandparents (Fong, 2004). This quest for good grades starts early. At the level of primary schools an elimination process is already set in motion. A second round of eliminations in terms of getting into a ‘good’ school occurs when your academic record determines if you can be admitted into a key senior high school (from grade 10 to grade 12). The final round of eliminations happens after the university entrance examination. At this point, you find out if you have passed or failed. Even if you pass, you need to wait to determine which university will accept you, and China’s

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universities are ranked. A first-tier university enrols only those students who have scored more than 600 points in the college entrance exam, whereas those who have scored below 430 but above 350 points in the university entrance examination will get into three-year programs to become junior college students. These programs cater to vocational education. Many children simply give up before they even reach the point to take the university entrance examination. For many young people self-respect comes from achieving high scores in school exams. It is a physically demanding and mentally distressing procedure. It is a humiliating process for those who fail in the race. The logic of this race is exclusion, denying a significant number of youngsters access to upward mobility. Under such circumstances, peer groups become especially important for those children who are defeated by the exams. Tight peer relationships among these students are a fundamental source of personal bonding and psychological comfort, providing them with a sense of belonging, dignity, sympathy and friendship. This is why teachers at Chinese schools often say that their best students do not have a lot of friends since they have to study very hard and remain competitive. By contrast, the less able students have many friends because they do not have great academic aspirations and have more time for their friendship groups. But the formation of intimate peer circles among the students who have failed in the exam race also leads to other outcomes, including a subculture of deviant behaviour which has been

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systematically documented in social research on juvenile crimes in China. These include: smoking, drinking, playing video games throughout the night, or arguing with their parents when they are asked to study harder. They also tend to acquire sexual partners at an early age. Some join youth gangs (see e.g., Liu, 2003; Sun, 2005; Zhong, 2008). But the students who are defeated by the exams do not give up what the education system preaches. The core of this popular philosophy of life is that a wonderful world of personal wealth and enviable styles of high life await the future adults if they now study hard and eventually get a key university’s degree, preferably a more advanced academic degree in the years ahead. Students who have failed at school are not immune to this much-preached philosophy of life, except that they are deprived of the legitimate means to arrive at the projected world of wealth. Many of these youngsters settle for instant gratification by mimicking what they believe to be the lifestyles of successful adults who smoke expensive cigarettes, wear fashionable clothes, drink imported liquor in KTV rooms, and attract the special attention of the opposite sex in discothèques. To put it more incisively, youngsters who behave in deviant ways have actually embraced the education system’s core values, which identify studying hard only as a tool for eventually accumulating personal wealth. Subsequently, critical thinking on the part of the student is severely discouraged. That some of the young people who are driven by this education system into

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a subculture of deviance which then leads them to the world of drugs is a profound social reality in contemporary China.

References AIDS Policy Research Center, Tsinghua University (2005), ‘Assessment Report of the China-UK Project’ (Zhongying aizibing fangzhi xiangmu pinggu baogao), kept at the AIDS Policy Research Center, Tsinghua University. Cao, Xiaoming (2005), ‘Probe into the Difficulties in Stopping Drug Use’ ( Jiedunan zhi tansuo), Journal of Sichuan Senior College of Police Officers (Sichuan jingguan gaodeng zhuangke xuexiao xuebao), no. 1, pp. 8–17. Dai, Yisheng (2004), ‘Analysis of Crime Trends among Juveniles in mainland China’ (Woguo dalu weichengnian ren fanzui zhuoshi zhi fenxi), Issues on Juvenile Crimes and Delinquency (Qingshaonian fanzui wenti), no. 6, pp. 4–8. Fong, Vanessa (2004), Only Hope: Coming of Age Under China’s One-Child Policy, Stanford, CA: Stanford University Press. Li, Peilin, Li, Qiang & Sun, Liping (2004), Stratification of Chinese Society (Zhongguo Sehui Fenceng), Beijing: Archival Press of Chinese Academy of Social Sciences. Li, Zongtao (2006), Sacrifice on Drugs ( Jidu), an unpublished manuscript kept at the AIDS Policy Research Center, Tsinghua University. Liao, Longhui (2001), ‘Sociological Analysis of the Current Situation and the Causes of Drug Use among Youth and Juvenile’ (Dangqian qingshaonian xiduxingwei jiqi chengyin de shehuixue fenxi), Youth Studies (Qingnian tansuo), no. 4, pp. 48–51. Liu, Neng (2003), ‘Juvenile Crimes in the Sociological Perspectives of Deviance’ (Yuegui shehuixue shiye xia de qingshaonian fanzui), Youth Studies, no. 11, pp. 30–37.

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Liu, Zhimin (2000), ‘Epidemiological Study on Reasons for Initial Drug Use among Opium Dependent Individuals’ (Arpian chengyinzhe chushi xidu yuanyin de liuxingbingxue diaocha), Chinese Journal of Behavioral Medical Science (Zhongguo xingwei yixue kexue), vol. 9, no. 2, pp. 123–125. Ma, Yongqing (2006), Drug Use: Deviant Behavior and Social Change (Xidu yuegui xingwei yu shehui bianqian), a doctoral thesis kept at the School of Sociology and Population Studies at the Chinese People’s University. Qian, Han-Zhu (2006), ‘Injecting Drug Use and HIV/AIDS in China’, Harm Reduction Journal, vol. 3, no. 4. This open-source article without page numbers for citation purposes is available at . State Council AIDS Working Committee (2004), A Joint Assessment of HIV/AIDS Prevention, Treatment and Care in China, 2004. Sun, Baohong (2005), ‘Neglect of Education in Social Responsibility and the Creation of Youth Developmental Problems’ (Shehui jiaoyu de shize yu qingshaonian fazhan wenti de shengcheng), Contemporary Youth Research (Dangdai qingnian yanjiu), no. 11, pp. 9–13. Wang, Baozhen (2003), ‘Sociological Analysis on Relapse of Drug Use’ (Xiduzhe fuxi wenti de shehuixe fenxi), Society (Shehui), no. 8, pp. 42–45. Wang, Jun (2006), ‘Analysis of the Factors Inf luencing Initial Drug Use among Drug Users in Urumqi’ (Xinjiang Wulumuqishi xidu renqun shouci xidu de yingxiang yinsu fenxi), Chinese Journal of Drug Use Prevention and Treatment, (Zhongguo yaowu lanyong fangzhi zazhi), vol. 12, no. 3, pp. 125–127. Wang, Longde (2007), ‘Overview of the HIV/AIDS Epidemic: Scientific Research and Government Response in China’, AIDS, vol. 21, no. 8, supplement, pp. 3–7. Zhu, Lin (2005), ‘Development of Research on Social Behavior of Drug Users’, (Xidu renqun shehuixingwei uinsu yanjiu jinzhan), Chinese Journal of Behavioral Medical Science (Zhongguo xingwei yixue kexue), vol. 14, no. 6, pp. 573–575.

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Zhuang Kongshao (2005), ‘Revelation of the Tiger’s Day Initiative in the Yi Ethnic Region of Xiaoliangshan’, (Xiaoliangshan yizu huri minjian jiedu xingdong he renleixue de shijian), Journal of Guangxi University for Nationalities (Guangxi minzu xuueyuan xuebao), vol. 27, no. 2, pp. 38–47.

Notes 1 First developed in Germany in 1937 as a substitute for morphine during surgery, methadone has similar effects as morphine, but it can stay in the human body for 24 hours, and thus it is more effective in controlling pain. In 2003, Chinese authorities approved the enrolment of heroin addicts at designated clinics to take methadone as a substitute for heroin. While it is also a highly addictive drug, methadone’s supplies can be controlled by authorities. The participants in China’s methadone program are considered ‘patient’, expected to first stop using heroin, then reduce dependency on methadone, and eventually become normal. At these policemonitored clinics, methadone is taken orally and information for disease prevention is provided. 2 Injecting heroin, usually intravenously but also by intramuscular or subcutaneous means, is cheaper than smoking heroin. This is because injecting makes maximum use of the heroin dosage and the full effect via injecting is experienced quickly, typically in five to ten seconds. 3 The three reports I have mentioned are the following: ‘Assessment Report of the China-UK Project,’ written in 2005 by the AIDS Policy Research Center at Tsinghua University; Sacrifice on Drugs, an unpublished manuscript written by Li Zongtao in 2006 and kept at the AIDS Policy Research Center, Tsinghua University; and Drug Use: Deviant Behavior and Social Change, a PhD thesis written by Ma Yongqing in 2006 and kept a the Chinese People’s University. The personal narratives of drug users that I cite throughout this chapter are adapted from these three documents, and I thank Li Zongtao for permission to refer to findings in her unpublished manuscript .

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4 This is an annual report published by the National Narcotics Control Commission since 1998. The national statistics of illicit drug use cited in this chapter derive from the annual reports of this government agency. 5 I have changed the personal names of all the drug users mentioned in this chapter to protect their anonymity and confidentiality. 6 For a systematic discussion on new forms of social stratification in China, see Li Peilin, Li Qiang and Sun Liping, 2004.

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4 ‘Red Oil’: Blood and the role of a machine in the HIV outbreak in central China Su Chunyan

F

rom July 2004 to October 2007, I conducted a study of the plasma trade in China by reviewing the existing literature and by interviewing rural people who had been paid plasma donors. I also interviewed doctors and government officials who were familiar with this particular trade. My primary research site was the village of Donghu in Xincai county, Henan province. The population of Donghu was little more than 1,500. Of the 160 people in the village who had been infected with HIV via the plasma trade, half had died by 2004. From Donghu, I moved to the city of Fuyang in Anhui province in 2005, also to gather information from paid plasma donors. In Fuyang, which borders Henan province and once had a thriving plasma trade too, I met Zhang Ying who ran a local non-governmental organisation that specialised in delivering assistance to children whose parents had either died of AIDS or were living with HIV. She helped me set up interviews with former plasma donors, and many of these respondents were the parents of the children she was working with. They all came from nearby villages. In 2007, I teamed up with Zhang Ke from a hospital in Beijing. We embarked on a research tour through a string of villages in Henan. A veteran HIV doctor, Zhang Ke had worked on treatment programs in

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Henan since 2004, and he introduced me to many of his patients. In total, I spent five months carrying out my fieldwork in Henan and Anhui. In the process, I interviewed more than 100 people who had first-hand knowledge of the plasma trade. As a result of this research, I became interested in the technology of plasmapheresis, for this technology played a major role in the HIV epidemic in Henan. However, before we launch into that, let’s look back to 28 October 2000, when the New York Times published an alarming report under the headline of ‘In Rural China, a Steep Price of Poverty: Dying of AIDS’ (Rosenthal, 2000). It was the first-ever exposé in international news media about HIV in Henan province. Before the New York Times article was published, a Chinese journalist had already reported on the HIV epidemic in Henan, but his article was published in a start-up newspaper and failed to draw much attention. The HIV outbreak in Henan province affected mainly people in rural areas who had tried to make a living in the first half of the 1990s via a blood market that collected whole blood for hospitals and plasma for pharmaceutical companies to produce medications. Local officials had known about this HIV epidemic for a few years (Su, 1997). Their effort to cover it up was dashed when Ms Gao Yaojie, a doctor of traditional Chinese medicine, broke the news to the New York Times. Following the New York Times article, Chinese reporters and foreign journalists went to Henan to investigate

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the situation, and their findings confirmed the gravity of the local HIV epidemic. By late 2003, the central government began to roll out an antiretroviral treatment (ART) program in Henan in response to the growing number of AIDS cases.1 In the same year, the Henan provincial government launched a sweeping epidem­ iological survey in rural communities where the HIV epidemic was known to be most serious. By 2004, Henan officials announced that 25,036 people in these communities had HIV, and that 11,815 of them also had AIDS-related conditions (Wang, 2004). The HIV epidemic in Henan had other causes than plasma donation. Patients who received blood and platelet transfusions and especially haemophiliacs who used a blood coagulant known as Factor VIII had also been infected. The most common form of haemophilia involves a genetic deficiency in Factor VIII. Regular infusions of plasma-derived Factor VIII can help haemophiliacs achieve normal clotting levels and prevent spontaneous bleeding. And apart from HIV, this trade in blood and plasma aggravated an existing hepatitis C epidemic and was related to a number of localised malaria outbreaks. No information has ever been provided by local officials or the Chinese central government as to how many people had died of AIDS in rural Henan, although a 2002 study by a team of researchers from Beijing found a staggering death toll in four villages there ( Jing et al., 2002). Led by Professor Jing Jun at

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Tsinghua University, this research team visited the villages of Shilipu, Houyang, Nandawu and Wenlou in Shangcai County, located in southeastern Henan province. The information they collected from local school teachers, rural doctors and village cadres reveals that the four villages had a combined population of 12,861 in 2000. Among these, 6,048 had sold blood and 1,362 had been tested positive for HIV. The combined death toll due to HIV in these villages was 601 by 8 August 2002.

The role of new technology Many academic papers and activist reports have been published about Henan’s plasma trade and the province’s HIV epidemic. (Shao, 2006; Erwin, 2006; Anagnost, 2006) But the role of a new technology known as ‘plasmapheresis’ also needs close examination because of the deadly role it played in the transmission of HIV among paid plasma donors in Henan. Invented in a Los Angeles hospital in 1959 as a method of extracorporeal therapy for treating a variety of disorders, including those of the immune system, the technology of plasmapheresis is a procedure in which plasma is removed from blood cells by a device known as a cell separator.2 The separator works either by spinning the blood at high speed to separate the cells from the f luid or by passing the blood through a membrane with pores so small that only the f luid part of the blood can pass through. The cells are returned to the person undergoing

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treatment, while the plasma, which contains the blood’s antibodies, is discarded and replaced with other f luids. Medication to keep the blood from clotting is given through a vein during the procedure. This therapeutically based procedure can be used for collecting plasma as well. Collecting plasma is similar in many ways to collecting whole blood donation, though the end product is used for different purposes. Plasma collection requires the use of a machine that separates plasma from blood cells by spinning at a high speed. Rural people in Henan who sold blood call this machine a ‘high-speed separator’. We will call this machine the ‘plasma separator’ for purposes of brevity. In Henan, bags of whole blood from multiple individuals, often five to ten people, were combined in such a machine. Once the plasma was separated, the blood cells were returned to the donors via tubes attached to the machine or by injections.2 This biomedical technology became known to some Chinese medical professionals in the 1980s and was adopted for collecting plasma in central China in the early 1990s. A medical scientist named Liu Junxiang was responsible for introducing the technology of plasmapheresis into China. In 1987, his Handbook of Plasmapheresis was adopted by the Ministry of Health as a technical guide for collecting plasma in China. Liu Junxiang had worked with scientists at Harvard University to invent a sophisticated and easy-to-operate plasma separator. His work at Harvard led him to the promotion of plasmapheresis

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as a new and innovative technology within China. Sensitive to safety issues, his handbook covered the history of plasmapheresis as a therapeutic procedure, its application to plasma collection, the importance of screening plasma donors to avoid spread of infection as well as mechanical procedures. In his book Liu emphasised that the use of these plasma separators requires building institutional capacities to ensure safety standards at blood banks so as to avoid serious mistakes, especially blood contamination and ischaemic shock.

Social risks vs technical risks In retrospect, the technical risks of using the plasma separators were anticipated by Liu Junxiang, and his safety advice was endorsed by the Ministry of Health. The social risks, however, of using these machines were not considered. By social risks, I refer to weaknesses in the social fabric around which the new technology was adopted for collecting plasma on a large scale. The first social risk was the huge gap in the expectations between the scientific aims of plasmapheresis and the for-profit motive of paid blood donation. On the one hand, Liu Junxiang and central health officials pushed for the application of plasma separators as an innovative technology. As the Ministry of Health anticipated technical risks in using this technology, it issued the plasmapheresis hand­ book as a government guideline for blood banks across China.

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On the other hand, the vast majority of blood banks had already embraced profit-making as their operational goal, and thereby considered the new technology simply as a convenient means of making more money. At the time, China’s blood supplies for clinical purposes mainly came from paid donors and compulsory sources, with an insignificant contribution from non-remunerated volunteers and a previously under­ ground blood market was operating openly throughout China. The profitable blood business attracted various investors who eventually built their own blood banks. These investors included local government officials, heads of military hospitals, private businessmen and even village cadres. The socioeconomic context in which the plasma machinery was adopted was blatant trade in blood and the eagerness to make a profit, and the trade operated by ignoring safety rules. The second social risk was a change of attitude among the rural population. Selling one’s blood as a way to make a living used to be a matter of shame, even in impoverished rural communities. What lifted this burden of shame was the legitimisation of an illegal and immoral business into one that was promoted by state-controlled blood banks and local government officials. In addition, the fast pace of economic growth at the time brought new wealth to a minority of ordinary people in rural China, and the new wealth stimulated increasing numbers of people to find ways to make fast money so they would not be seen as falling behind in the new age of

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China’s economic reforms. There was also the effect of social emulation. For example, the visible and quick improvement of living conditions for a handful of individuals in a village who were selling their blood served as a catalyst for hundreds of people in that village to trade their blood to blood banks for instant cash. The third social risk was the lack of enforcement of blood safety regulations. National policies stipulated that blood banks must be penalised by local governments if found to have violated standard procedures, including screening donors, the compulsory wearing of gloves and masks by all staff, and careful handling of equipment. National policies stipulated that only qualified and licensed technicians were allowed to handle the plasma separators. But instead, these machines were operated by medical practitioners with little technical training in plasma collection and even fell into the hands of local blood contractors who had no medical training at all. In a rush to turn the blood market into a pillar of local economic growth, government officials in rural counties and small cities ignored what was happening inside the blood trade. This problem was most acute in Henan where the head of the provincial health bureau regarded plasma as ‘red oil’ and went as far as helping his relatives to invest in the plasma trade. Set against this background of social risks, the plasma machinery’s technical risks were bound to end in disaster. To begin with, HIV testing via ELISA (enzyme-linked immuno­

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sorbent assay) and Western Blot technologies was restricted in Henan in the 1990s, since there was a serious lack of both laboratory capacity and trained personnel. But government policies did require HIV-related disease diagnosis through medical examinations and inquiries about sarcoma and palpation of cervical lymph node swelling. Donors should be rejected if they were diagnosed as physically unqualified. In addition, testing was required for HBV (Hepatitis-B virus). Despite all these policy requirements, little action was taken at the grassroots levels. Blood bank managers knew that some of the paid donors had various infectious diseases but did little to prevent them from selling blood, according to a report by the Central China Television on 2 September 2001. Rules and regulations were enforced only half-heartedly, allowing donors to use pseudonyms to sell blood. An extreme example of identity deception was the use of personal names of celebrities such as nationally known actors and popular singers. This confusion of donor identities means that donor records were unreliable and that therefore it was almost impossible to track down the sources of blood donations when they were found to be contaminated. Blood was also contaminated as a result of damage to some of the blood bags put in the plasma separator during the spinning process, or by using contaminated scissors to cut the tubes attached to the machines. Intravenous needles for local anaesthesia were reused repeatedly, although the stated

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requirement was one needle per person. In hospitals that engaged in the plasma trade, the plasma collection units and the clinical departments shared the same disinfection equipment, leading to cross-infections between plasma donors and hospital patients. Sometimes, the unwanted blood cells of one donor were injected into the veins of another donor. The practice of re-injecting the unwanted blood cells back to the donors was based on a myth created by blood banks. These re-injected blood cells were said to enable a donor to produce more blood so that he or she could sell blood more frequently.

Conclusion: economic development above social development The careless use of the plasma separators at the peak of central China’s blood trade and plasma market was characteristic of a time during which Chinese national leaders placed economic development above social development. The annual increase of Gross Domestic Product (GDP) was then considered as an objective measure of the government’s leadership in the creation of a vibrant market economy. GDP goals were set by central authorities for local governments through economic forecasts, making career promotion of civil servants dependent on the realisation of these forecasts. The GDP mentality explains why the once-underground

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blood market emerged above ground and why plasma was considered as ‘red oil’ by the former head of Henan provincial health bureau. In the city of Fuyang in Anhui province, for example, trade in blood was enthusiastically promoted by government agencies trying to please a mayor who manifested his eagerness to advance his official career by demonstrating the city’s GDP achievements. The GDP mentality also created a political and administrative environment in which blood banks proliferated at an alarming rate. The plasma trade extended its reach from its beginnings in Henan and covered seven provinces in central China. Certification of blood banks was made easy to obtain in these provinces. Academic institutions specialising in research on blood transfusion were allowed to run companies to develop plasma-based medications. Military hospitals were given the green light to collect blood from civilians. And private businessmen with powerful connections within government agencies were enabled to establish their own blood banks without having to demonstrate their qualifications. This political and administrative environment made it possible for local government officials to turn a deaf ear to warnings based on reports of irregularities from deeply concerned medical doctors at the grassroots. Even reports of HIV found in plasma shipments to pharmaceutical companies were ignored. It was not until the outbreak of Severe Acute Respiratory Syndrome (SARS) in 2003 that the Chinese

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government started taking seriously infectious diseases, including HIV. Under the new leadership headed by President Hu Jingtao and Premier Wen Jiabao, the GDP mentality abated and was replaced by the policy of maintaining social stability. This explains why the Chinese government has reacted decisively in response to the SARS epidemic, the outbreaks of the Avian Flu and Swine Flu since 2003. It also explains why the Chinese government has engaged in an unprecedented effort to combat the impact of the HIV epidemic since 2003. The technology of plasmapheresis now continues to be used in China and plasma donations continue to be remunerated. The difference is that a much tighter certification requirement has been set in place, and all blood banks are forbidden to engage in the plasma trade. Only pharmaceutical corporations that are directly engaged in the manufacturing of plasma-based medications are allowed to collect plasma, and they must prove that they have effective safety standards in practice, starting with compulsory screenings for HIV and Hepatitis B. In the past few years, no irregularities in plasma collections have been reported in the Chinese news media. In other words, the technology of plasmapheresis can be used safely if its regulatory environment is viable.

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References Anagnost, Ann (2006), ‘Strange circulations: the blood economy in rural China’, Economy and Society, vol. 35, no. 4, pp. 509–529. Erwin, Katherine (2006), ‘The Circulatory System: Blood Procurement, AIDS, and the Social Body in China’, Medical Anthropology, Quarter l, vol. 20, no. 2, pp. 139–159. Jing, Jun (2006), ‘A Prediction by Titmuss’ (Tiemosi Yuyan), Open Times (Kaifang Shidai), no. 6, pp. 71–88. Jing, Jun et al. (2002), ‘AIDS and China’s Poverty Reduction’ (Aizibing yu Zhongguo Fupin Gongzuo), in Jin Wei (ed), Textbook on AIDS Policy for Chinese Cadres (Aizibing Fangzhi Ganbu Zhengce Duben), Beijing: Publications of Central Party School (Zhonggong Zhongyang Dangxiao Chubanshe), pp. 226–241. Liu, Junxiang (1987), Handbook of Plasmapheresis (Xuejiang Dancaishu Shouce), Beijing, the Chinese Health Press. Rosenthal, Elisabeth (2000), ‘In Rural China, a Steep Price of Poverty: Dying of AIDS’, New York Times, 28 October, p, A1 & p. A 4. Shao, Jing (2006), ‘Fluid Labor and Blood Money: The Economy of HIV/AIDS in Rural Central China’, Cultural Anthropology, vol. 21, no. 4, pp. 535–569. State Council AIDS Working Committee Office (2004), Joint Assessment of HIV/AIDS Prevention, Treatment, and Care in China. Su, Huicun (1997), ‘Analysis on the Data of the Blood Transmitted Diseases in part of Plasma Donors in Henan Province’ (Hennansheng Bufen Xianxuejiang Renqun Xueyuanxing Chuanbo Jibing Jiance Jieguo Fenxi), Diseases Surveillance ( Jibing Jiance), vol. 12, no. 7, pp. 251–253. Wang, Amin (2004), ‘Henan Government Reconfirms the HIV Epidemic’ (Henan Aizibing Yiqing Chongxin Queren), Xinhua News Agency, 10 September.

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Notes 1 The policy guiding this treatment program is called ‘Four Free and One Care’, promulgated by the Ministry of Health and put into effect on 1 December 2003. It is covered in more detail in Chapter 5. 2 The social implications involved in using the technology of plasmapheresis for the sole purpose of collecting plasma so as to make medications have received little attention from scholars in China or elsewhere. Much of the background information regarding this technology is based on Liu Junxiang’s handbook on plasmapheresis, published by the Chinese Health Press in 1987. In addition to my interviews with former plasma donors in Henan and Anhui, information on how this technology was used in hazardous ways is based on public statements made by AIDS activists such as Gao Yaojie and Wan Yanhai, and government officials such as Sun Xinhua and Qi Xiaoqiu in the Ministry of Health.

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5 Fears of Identity Exposure among Gay Men Living with HIV Zhang Yuping

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hinese gay men who are living with HIV have serious concerns about their identity being exposed via medical and social services. The central argument of this chapter is that keeping the homosexuality and HIV-positive status of these men confidential is the precondition of effective care and treatment. At present, in China’s response to HIV issues of confidentiality are not properly handled, as the delivery of medical or social assistance to people living with HIV often poses a threat to their need for identity protection. In 2008, for example, a policeman in Yunnan province stopped a gang fight and was wounded in the process. He was sent to hospital where a blood test found him to be HIV-positive. When the test result was leaked to his superiors by the hospital’s authorities, he was stripped of his medal for bravery. Also in 2008, a couple living with HIV in the city of Gejiu were told by a local school that their child could no longer be a student there. In dealing with their subsequent lawsuit against the school, a local court found that the couple’s HIV status had been exposed by a communitybased welfare agency. Their child did not have HIV but some parents still considered him a health threat and they got together to lobby the school’s authorities to prevent him from attending classes.1

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Gay men living with HIV in China are fearful that violations of confidentiality via medical or social services would lead to a double exposure, the consequences of which would be grave for them. First, if exposed, they would be rejected by gay communities because they have HIV, and second, would be discriminated against by society at large because they are both gay and HIV-positive. Much of the discussion in this chapter draws on my research in the city of Chengdu. In 2004, I spent a month there to conduct an observation-based study in a gay bar, followed by formal interviews in 2005 with gay men I had met in the previous year. Assisted by the Chengdu Gay Care Organization, a local non-government organisation, my study was an attempt to understand how Chinese gay men perceive their sexual orientation, what they do in their leisure time, and how they react when they are under parental pressure to get married. In the years that followed, I returned to Chengdu several times to keep up my contacts. In October 2007, I interviewed 28 gay men living with HIV in Chengdu. All these men were associated with the Chengdu Gay Care Organization. The bulk of my discussion in this chapter will be based on these interviews.

Gay men in China’s response to HIV For nearly 20 years after China’s first HIV case was reported and confirmed in 1985, China’s response to HIV concentrated

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on injecting drug users and female sex workers. The country’s nationwide HIV surveillance focused on these at-risk groups as well as paid blood donors and people living with sexually transmitted infections (STIs). By contrast, men who have sex with men (MSM) remained neglected in China’s HIV sur­ veillance effort, in spite of lessons that could have been learned from countries where HIV has severely affected gay men. China’s HIV surveillance among gay men started only in 2003 and was limited to two sites. This lack of effort to survey and test gay men for HIV was at the root of the complacency among Chinese health officials and gay communities. So in retrospect, it is not surprising that the gay communities in Chengdu had a laid-back attitude about HIV when I began my research there in 2004. At the time, even the leaders of the Chengdu Gay Care Organization, founded in 2002, did not fully believe that gay men were threatened by HIV. They wanted discussions on HIV and male homosexuality to be delinked, because they personally knew only a handful of gay men living with HIV. In 2004, for example, only two men in their organisation tested HIV-positive. Although this organisation was already conducting HIV education, and even arranged community-based HIV tests, its leaders were not truly concerned about HIV – not until 29 people in the organisation were discovered in 2006 and 2007 to be living with HIV. In 2008, the Chengdu Gay Care Organization scaled up their community-based prevention efforts and persuaded 1,323 of its

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associates to be tested. They immediately found 186 HIVpositive cases. This rapid increase of HIV infections among gay men in Chengdu was consistent with a national trend. In 2008, the Ministry of Health organised a survey and HIV testing of 180,000 gay men in 61 Chinese cities and found the HIV prevalence to be five per cent. In one city, the prevalence rate was 15 per cent (Xinhua News Agency, 30 November 2009). The study also found that many gay men living with HIV were married and thus there was a significant potential for the transmission of HIV via unprotected conjugal sex. These findings convinced the Ministry of Health that the HIV situation in the country’s gay communities had reached the level of an epidemic and that gay men must be considered as a ‘most-at-risk’ population in China’s response to HIV.

Changing attitudes and behaviours among gay men From the early 1950s to the late 1970s homosexuality was a crime in China. Once known to police authorities, gay men were often arrested and sentenced to jail on sodomy charges. By the early 1980s, however, homosexuality was no longer identified as a special category of sexual crime in the Chinese Criminal Law. This led to a gradual visibility of gay activities in large cities.2 I learned during my research in Chengdu that a

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culture of sexual abstinence was embraced in the local gay communities throughout the 1980s. Anal sex was rare, and commercial sex extremely uncommon, and kissing, touching and mutual masturbation characterised physical intimacy among men. In the 1990s, however, oral and anal sex gradually became more prevalent. Male sex work, nonetheless, remained rare and was frowned upon when it was uncovered. After 2000, however, commercial sex established itself through a burg­ eoning of gay bars, nightclubs and bathhouses and instead of being subjected to peer condemnation, commercial sex began to be taken for granted. These significant changes in behaviour and attitude in Chengdu conformed to a larger trend in urban China, which was documented by a series of sociological and public health studies. These include a sociological study by Li Yinhe and Wang Xiaobo in the late 1980s (Li & Wang, 1993; Li & Wang, 1994),3 a multiple-site sociological survey by Pan Suiming and Wu Zongjian in the early 1990s (Pan & Wu, 1993; 1994) and a series of epidemiological studies by Zhang Beichuan in the 2000s (Zhang et al., 2001; 2002; 2008). The increase in riskier behaviours among Chinese gay men over time has been accompanied by a significant increase of reported HIV cases. At the same time, the possibility that gay men living with HIV may become a vector of secondary infections amongst their wives became a reality. Although safe sex is a matter of common knowledge among Chinese gay men, condom use with female partners remains problematic

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because it poses barriers to interpersonal trust and may even suggest that the condom user has STIs. This situation is made more complex by the enormous societal pressures on gay men to get married and have children. Such pressures come from parents, siblings, colleagues or friends who are heterosexuals. In a culture where filial piety is valued highly (which also means keeping the family line unbroken), marriage is expected to lead to the birth of a child, preferably a boy. Rooted in the Confucian ideals, filial piety is one of the Chinese virtues to be guarded above all else. Under the pressure of social norms and the urging from within their own families, most Chinese gay men marry when they cannot put it off anymore. According to Zhang Beichuan, a leading authority on male homosexuality in China, at least 80 per cent of Chinese urban gays marry under social pressure. Sexologist Liu Dalin, however, believes that this figure is higher: around 90 per cent of all gays in China, because gay men in rural areas are under greater social pressures to marry and have children (Xinhua News Agency, 30 November 2009). The social pressure on gay men to marry and have children produces a situation in which HIV may be passed from gay men to women. Avoiding this possible consequence is difficult, because to marry, gay men must hide their homosexual desires from their future wives. Once married, many do not want to inform their wives that they are gay and therefore they must keep their homosexuality a secret. As a child is the expected outcome of a marriage, sexual intercourse without

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any form of contraception must occur. Many married gay men find excuses for using condoms or concoct lies for not wanting intercourse. But when their excuses run out, unsafe sex occurs.

The double burden Concealment of their sexual identity is part of everyday life for gay men in China. But for those who are gay and live with HIV, concealment takes on a much greater weight. In the process of my interviews with 28 gay men living with HIV in Chengdu in 2007, I became keenly aware of what they described as ‘a double burden’. At its core is the issue of confidentiality. In addition to their anxiety over their health, these men said that they often despaired over the possible exposure of their homosexuality and HIV-positive status. The 28 gay men I interviewed were between 17 and 41 years of age. Their average age was 28. Of these, 27 lived in Chengdu, and one lived in a nearby town. Half the respondents had a college degree, 12 had finished the compulsory nine years of schooling, and only two did not receive further education beyond primary school. None had a history of drug use. Six were married and four of these had children. All except one knew how they got infected with HIV. Half of these men were diagnosed in hospitals and local centres for disease control. The others were tested through the Chengdu Gay Care Organization. None had received any professional psychological

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counselling after being tested positive. Only five had medical insurance. The youngest respondent, aged 17, was accompanied by his lover in the interview process. The occupations and income levels of the respondents varied a great deal. At the top end was a young man working in a nightclub. He made 100 to 200 RMB (AUD 35) per night. At the lower end was the 17-year-old boy. He worked at an internet bar for a monthly salary barely enough to cover the cost of his food. The interviews were semi-structured and open-ended, with topics covering life history, sexual partners, family background, occupation, initial reactions on being diagnosed HIV-positive, medical needs and opinions on local gay men’s preparedness in dealing with HIV. Each interview lasted approximately one hour, with additional time allocated for explaining the purpose of the interviews and for filling out a consent form. The interviews were conducted in a hotel and audio-taped with the permission of all the respondents. Despite the differences in age, marital status, occupation or education, these individuals all feared the same thing: the exposure of their identities, and they said this fear was aggravated by the ways in which testing, care and treatment could expose their gay identity and HIV status. Absolute concealment of both those things was what they cared about most. The ultimate price they had to pay if they were exposed, they explained, would be total rejection by local gay communities because of their HIV status, and public discrimination because of their

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homosexuality. This double exposure would serve as a blow to their sense of belonging on the one hand and might even result in their loss of employment on the other. It must be noted here that China has laws to protect people living with HIV in terms of employment, medical services and education. And yet, employers can find excuses to terminate labour contracts if they object to people who live with HIV or who are homosexual.

A secret from their community Concealment of their HIV status is an absolute necessity within the gay community and imposes a heavy burden on gay men living with HIV, said the respondents. Bars, nightclubs and bathhouses dominated by gays in Chengdu form an essential part of these men’s life in this city, which is known for a higher degree of tolerance of homosexuality compared to other Chinese cities. Even so, HIV is taboo, and gay men with HIV are shunned at these establishments. According to these respondents, to continue being part of a community of men whose sexual identity is similar to theirs, gay men living with HIV tend to keep their sero-positive status secret. It is not, however, simply because of their desire to continue sexual activities that they would not tell their friends about their status. As a man in his late 30s put it, ‘I stopped having sex after I found out about my HIV status. But I still want to see my friends.’ The emotional attachment to the gay community is so

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strong that gay men living with HIV would try to stay connected to these communities as long as possible, even when it means that they might be regarded as having been dishonest if their secret is discovered by HIV-negative gay men. The interviewees specifically requested that the interview schedule be arranged in such a way that there was a 15-minute interval between each one so they would not run into one another. In other words, they even feared being outed by other gay men living with HIV.

A secret from the family For these men, hiding their homosexuality and their HIV status from their parents is a top priority. A man in his late 20s said that he feared that his parents would be heartbroken and even die if he told them that he was a gay man living with HIV. Born and brought up in an industrial city not far from Chengdu, this young man became aware of his sexuality after he graduated from college. He suppressed his homosexuality, partly because he was ashamed of it, but also because he needed to appear ‘straight’ because he was a leader of the youth league at a stateowned enterprise where he worked. On a visit to Chengdu, he saw a note and a phone number written on the wall of a men’s room implying homosexual friendship. He later found out that the phone number belonged to a young man in a city in northwest China. They communicated by phone and internet for several months. Then he visited his new friend and had his

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first-ever homosexual experience. A month after he returned home, he was diagnosed with HIV through a hospital blood test. His sister was the only person who later came to know that he was a gay and had HIV. ‘I asked my sister to take a walk with me over a little hill where I told her about my secret,’ he recalled. ‘She tightened her lips so she would not cry out. She then responded by ordering me not to tell our ageing parents. She said they would not understand why I am gay and they would be saddened even more if they heard I have this kind of disease.’ After his conversation with his sister, he left his home town for Chengdu. In the short space of two months, he had sex with more than 60 men. ‘I was totally wild. Most of the men I encountered were complete strangers,’ he revealed. He did, however, use condoms during these encounters because, he said, ‘I want to protect them. I would have walked away if they had objected to condoms.’ When asked if he would ever tell his parents of his HIV status, he replied that he would try to keep it secret as long as possible. ‘A filial son does not cause trouble to his parents,’ he emphasised.

Care and treatment in the eyes of gay men living with HIV In order for HIV-positive people to receive timely treatment and care, China introduced a ‘Four Free and One Care’ policy

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in 2003. This policy offered free HIV tests, free antiretroviral drugs, and waivers of school fees for children of couples living with HIV, free drugs for the prevention of mother-to-child transmission, and the provision of social relief to patients living in poverty. But all these benefits depend on household registration, which means that they are available only in the home town where the permanent residence of an HIV-positive person is officially registered. A Chinese household registration record identifies a person as a permanent resident of an area and includes information such as the name of the person, his or her date of birth, the names of his or her parents, and the spouse’s name, if married. The government restriction on access to medical services, and especially antiretroviral drugs, by residence registration is a special obstacle for people living with HIV who work and live away from their home towns. These include gay men. Chinese gay men born and brought up in small towns and rural areas migrate to large cities for employment. They return to their home towns mostly during the Chinese New Year for the purpose of family reunions. One driving force behind this migratory habit is their fear of social discrimination in small towns and rural communities where people tend to know one another. As well, parental pressure for gay men to marry drives them away from their home towns. Furthermore, leaving rural villages and small towns for large cities gives them the freedom to meet other gay men and find a gay community.

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Return to their home town for antiretroviral treatment would be a nightmare, said some of my informants, who believed that medical practitioners in small towns could not or would not help them conceal their status. A young man in his early 20s said that he f led from his home town after the secret of his HIV status was leaked. He was tested positive in the military and immediately discharged. When he got back home, he found his parents wailing. It turned out that doctors in his military unit had leaked his test result to local doctors who then told his parents about his HIV status. Fearing that his HIV secret would be divulged to other people in his home town, he left home in anger. He went to Chengdu where he found a decently paid job but started drinking heavily. He said that he wanted to make a lot of money quickly so he could repay his parents for their kindness. ‘I may die before them. Making a lot of money for my parents is my way of showing them that I am a filial son,’ he said. Even if gay men living with HIV do not want other people to know their health status, their secret cannot be kept from the doctors who test and treat them. And since there is so much fear of stigma and discrimination, the attitude of medical practitioners toward homosexuality is a matter of great sensitivity. A slight change of tone or facial expression on the part of a doctor or nurse can be perceived by gay men as an indication of veiled prejudice against them. Furthermore, adherence to the government restriction of antiretroviral

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treatment because of the requirement of household registration could be interpreted as if it were a personal decision on the part of the medical practitioners. One of the respondents said, for example, that the doctors did not act quickly to deal with a shortage of antiretroviral drugs at a designated treatment centre because they did not take their gay patients very seriously. ‘My CD4 is decreasing quickly, and it is quite low. But up till now my biggest difficulty is to get the drugs. These drugs have been delayed for two months,’ he related. ‘The doctors seem to be discriminating against us even more than against this disease. They make it so difficult for us to get the drugs. I am an outof-towner. Initially, they refused to give me any drugs, and they said that I should go back to my home town to be treated. But if I go home for these drugs, it is like announcing to everyone that I am infected with this disease. If that happens, I cannot live anymore. I am very concerned for my child. She is very pretty and kind. She is an excellent kid. I can give up anything for her. For her, I can die. People all know each other in my home town. If I get antiretroviral drugs there, people will suspect that I have HIV,’ he explained. Distrust of the medical establishment creates an obstacle not only for treatment but also for prevention. A respondent who worked for a corporation said that what made him worry was that his HIV status would be revealed through regular physical check-ups arranged by his company. He had avoided these check-ups because he feared that they included HIV testing and

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that doctors would inform his employers of his status. ‘When corporations ask their employees to have their health examined, I do not know if they are even allowed to test people for HIV. It seems to me that this is a very private matter. I do not want to be laid off by my company simply because I have this disease. I do not want my health status to have any negative consequences on my career. If one day this happens to me, I will die because I cannot continue to work. It is very important for me that I have a job.’

Stigmatisation among healthcare providers The fear felt by the gay men I interviewed is not imagined. While discrimination against homosexuality is a societal problem, the tendency to stigmatise people living with HIV is a particular problem within China’s medical community. A recent study of attitude among 659 medical practitioners in a rural county (Lu et al., 2008) found that 35 per cent of the respondents did not wish to continue working with their colleagues if their fellow doctors or nurses were HIV-positive. And more than half of these respondents said that they would sever their marital relations if their spouses had HIV. In a larger attitudinal study among 1,292 doctors, nurses and administrators at 32 hospitals in Beijing (Liu, Liu & Yu, 2008), it was found

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that nearly 10 per cent of the respondents were against providing equal access to medical services for HIV-positive patients. In addition, 49 per cent of these respondents said that they would prefer to avoid treating AIDS patients. Even among those who specialise in prevention and control of infectious diseases, attitudes to people with HIV and AIDS are not any better. For example, a 2006 study among 415 staff members at a selected number of provincial, city and country centres for disease prevention and control found a high degree of HIV-related discriminatory attitudes (Peng et al., 2006). At the provincial centres, for example, nearly a quarter of the respondents considered HIV as a punishment for immoral behaviour and the rate of opposition to safeguarding the confidentiality of AIDS patients was as high as 9 per cent. Considering these attitudes among medical practitioners and public health workers, the fact that Chinese gay men living with HIV are terrified of double identity exposure is hardly surprising. Effective HIV care and AIDS treatment needs a sweeping change of attitude in China’s medical community.

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References Hinsch, Bret (1990) Passion of the Cut Sleeve: The Male Homosexual Tradition in China, Berkeley, CA: University of California Press. Li, Yinhe & Wang, Xiaobo (1993), ‘Pilot Study on Chinese Male Homosexuals’ (Guanyu zhongguo nan tongxinglian wenti de chuben diaocha), Chinese Youth Studies (Qingnian yanjiu), no. 1, pp. 33–34. Li, Yinhe & Wang, Xiaobo (1994), A World of Men (Tamen de shijie), Shanxi People’s Publishing House. Liu, Jun, Liu, Min & Yu, Da (2008), ‘The attitude towards people living with HIV and AIDS (PLWHA) and AIDS knowledge and desire for AIDS related training among 1293 health workers in selected hospitals in Beijing’ (Beijingshi 1293 ming yiwu renyuan AIDS xiangguan zhishi taidu ji peixun xuqiu diaocha), Chinese Journal of AIDS & STD (Zhongguo aizibing xingbing zazhi), vol. 13, no. 2, pp. 130–133. Lu, Songhe, Zhang, Meiying & Xiao, Dan et al. (2008), ‘Research on Intervention of Discrimination against PLWHAs among the Health Care Services in Zhen’an’ (Zhen’an xian yiwu renyuan fan PLWHAS qishi de yanjiu), Progress in Modern Biomedicine (Xiandai shengwu yixue de jinzhan), vol. 8, no. 8, pp. 1468–1471. Pan, Suiming & Wu, Zongjian (1993),’Sexual Relations in the Socialization of Chinese Gay Men’ (Zhongguo nan tongxinglian shejiao zhong de xing guanxi), Youth Studies (Qingnian yanjiu), no. 12, pp. 32–35. Pan, Suiming & Wu, Zongjian (1994), ‘HIV Risks in Socialization of Chinese Gay Men’ (Zhongguo nan tongxinglian shehui jiaowang zhong de aizibing fengxian), Zhejiang Academic Journal (Zhejiang xuekan), no. 5, pp. 66–69. Peng, Zhibin, Li, Dalin & Jiang, Honglin (2006), ‘Knowledge, Attitude and Practice about HIV/AIDS of Public Health Professionals in Some Areas of China’ (Zhongguo bufen diqu jibing yufang kongzhi gongzuo renyuan HIV/AIDS zhishi taidu ji xingwei diaocha), Chinese Journal of Drug Dependency (Zhongguo yaowu yilai zazhi), vol. 15, no. 1, pp. 49–52.

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Ruan, Fang-fu & Tsai, Yung-mei (1988), ‘Male homosexuality in contemporary mainland China,’ Archives of Sexual Behavior, vol. 17, no. 2, pp. 189–199. Xinhua News Agency (2009), ‘A New Wave of HIV Outbreaks in China’ (Zhongguo aizibing xin yi lun baofa), 30 November. Zhang Beichuan et al. (2001), ‘Survey on the high-risk behaviors related to acquired immunologic deficiency syndrome and sexually transmitted diseases among men who have sex with men in mainland China’ (Zhongguo dalu nan nan xing jiechuzhe aizibing xingbing gaowei xingwei qingkuang diaocha), Chinese Journal of Epidemiology (Zhongguo liuxingbing xue), vol. 35, no. 3, pp. 214–216. Zhang, Beichuan et al. (2002), ‘Survey on the High Risk Behaviors and Other AIDS/STI Related Factors among Men Who Have Sex with Men in Mainland China in 2001’ (2001 nian 1109 li nan nan xing jiechuzhe xingbing aizibing gaowei xingwei jiance yu diaocha), Chinese Journal of Dermatology (Zhonghua pifuke zazhi), vol. 35, no. 3, pp. 214–216. Zhang, Beichuan et al. (2008), ‘Correlation between AIDS and homosexuals: A study of 2046 male homosexuals in nine major cities of China’ (Zhongguo jiu chengshi 2046 li nan tongxinglianzhe yu aizibing xiangguan zhuangkuang diaocha gaikuo), Chinese Journal of Human Sexuality (Zhongguo xing kexue), vol. 17, no. 8, pp. 6–9.

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Notes 1 Information about the policeman who was stripped of his medal for bravery because he had HIV was related to Professor Jing at Tsinghua University by local residents of Jianshui during a research tour he took in December 2008. Information of the lawsuit on the city of Gejiu has been widely reported in the local press in Yunnan. 2

On the history of male homosexuality in China, one is best advised to read Bret Hinsch’s Passion of the Cut Sleeve: The Male Homosexual Tradition in China (1990). For a concise and informed review on male homosexuality in China from the 1950s to 1980s, one could refer to ‘Male homosexuality in contemporary mainland China’, written by Ruan Fang-fu and Tsai Yung-mei (1988).

3 Li Yinhe and Wang Xiaobo’s study of gay men in China, which began in 1989 and ended in 1991, is now considered the first-ever sociological study of its kind within mainland China. Li Yinhe later went on to study Chinese lesbians, while Wang Xiaobo dropped out of sociology and became a nationally celebrated novelist.

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6 Disclosure and Condom Use after HIV Diagnosis Sun Yongli

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ne of the purposes of the various forms of HIV testing around the world is safer-sex techniques to prevent secondary infections. This explains why counselling services for HIV-positive individuals are required to stress, among other things, the importance of safe sex ( Jing, 2005; Ma, 2006). The assumption behind this kind of health advice is that many HIV-positive people will continue to have sex and that some of them will continue to have multiple partners. But for the preventive purpose of HIV testing and counselling to be realised, those living with HIV must use a condom in vaginal or anal intercourse. And when questions about why a condom should be used are asked, being HIV-positive may be one of the reasons, although this requires that the HIV-positive person discloses their status. Thus, behavioural research on HIV is frequently concerned with the degree of HIV disclosure and the regularity of condom use in the aftermath of HIV diagnoses (Wang et al., 2007; Yang et al., 2005; Zhao et al., 2005). By the same token, social researchers often ask and address the question of why HIV disclosure or condom use is not an easy task to achieve, even after one is diagnosed with HIV (Patel et al., 2003; Sarit et al., 2008; Courtenay-Quirk et al., 2008).

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In China, HIV testing is compulsory in hospital before invasive procedures and in the antenatal clinic and labour ward. Hospital-based HIV testing is a paid-for service (Liu et al., 2007). By contrast, free voluntary counselling and testing (VCT) is offered by a nationwide network under the Centre for Disease Control and Prevention ( Jin, 2008). In addition, throughout China prisoners, and especially incarcerated drug users, are required to undergo HIV testing (Zheng et al., 2007).1

Kaiyuan study To address some of the key issues associated with disclosure and condom use following the diagnoses of HIV, this chapter will examine a body of information gathered from 131 Chinese citizens who had been diagnosed HIV-positive in 2007. On the basis of this information, I argue that HIV disclosure is not a simple act of revealing a sexually transmitted infection (STI) to one’s sex partners. People living with HIV make choices about who should be informed or who should not. Similarly, condom use depends on personal relations that engender the specific context in which sex occurs. For those individuals who have multiple sex partners, for instance, using a condom is a matter of practising safe sex with some partners but not with others. This argument is a reaction to research in China on the impact of HIV testing that has focused on behavioural changes alone.

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For example, a number of Chinese researchers found that knowing one’s HIV status led to an increased condom use in sexual intercourse (Marks 2006; Marks et al., 2005; Jin et al., 2009). But neglected in these studies was the discussion about why some people told their partners that they had HIV, while others did not. Also neglected was the varied degree of condom use with different types of partners. Put another way, a person living with HIV may have several sexual partners and could have a very different kind of personal relationship with each of them. It would be foolhardy to assume that identical considerations of HIV disclosure and condom use would be applied to all of one’s sex partners. HIV status is disclosed and condoms are used according to the dynamics of personal relationships. The argument I have outlined above is derived from a study of 131 HIV-positive men and women from the city of Kaiyuan in the southwestern province of Yunnan.2 Conducted by the National Centre for STD/AIDS Prevention and Control in 2007, the Kaiyuan study included 23 female sex workers, 85 injecting drug users, eight men who had paid for sex, and 15 men and women whose spouses or sexual partners had HIV and then unknowingly passed the virus to them. As a research associate in this study, I went to Kaiyuan to help administer a questionnaire and conduct some of the interviews. The respondents who took part in our study were recruited from medical institutions that offered antiretroviral treatment to

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HIV patients and methadone treatment to injecting drug users in Kaiyuan. The respondents gave informed consent and were interviewed at settings of their choice, mostly in local hospitals and clinics. In these settings, the identities of the HIV-positive individuals were known to medical professionals and yet could be protected from outsiders. The median age of the 131 respon­ dents was 35.5. Han Chinese made up 76 per cent of all the respondents. The others were from various ethnic minorities commonly found in the city of Kaiyuan. The bulk of this group had completed China’s nine years of compulsory education. Twenty-five per cent had not. Four were illiterate. Nearly 40 per cent of the respondents were single who lived alone. Nearly 33 per cent were married. Four had lost their spouses and 18 were divorced. The others were cohabiting with their partner. When the data on sexual behaviour before and after diagnosis was analysed, the first thing we discovered was the lack of any significant decrease in sexual partners after the respondents’ HIV diagnoses. But a number of other issues relating to sexual practice changed as a result of their knowledge that they had HIV.

Main findings of the study One of the key questions we asked these respondents was about HIV disclosure to their sex partners. Studies in China on this

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issue have revealed a great reluctance among HIV-positive people to disclose their HIV status even to their own parents, spouses or close friends. We had assumed that we would find the same pattern in our study in Kaiyuan. Our findings, however, suggest otherwise (at least to some extent), because nearly 30 per cent of our respondents said that they told their spouses or regular sex partners about their HIV status. Some of the men in our study said that they even revealed their HIV status to sex workers whom they cared about and patronised regularly. It was the casual sexual partner – the one-night-stand or random sex worker – whom the respondents were the least likely to inform. The rate of HIV disclosure was highest – 29 per cent of all the respondents – to spouses or regular partners. That figure was halved when they had casual sex with people they did not know at all, or did not know well. This pattern of disclosure, as I see it, follows the principle of psycho-social distancing. That is, those who were close to the respondents either because of affective relations or social attachments were more likely to be informed than those who were not. When it came to condom use in the first 30 days following HIV diagnosis, the same principle of psycho-social distancing was applied; however, it should be noted that this principle worked in a reverse fashion. For example, the rate of condom use was much higher when having sex with casual partners than with spouses and regular partners. Specifically, nearly 70 per cent of the respondents said that they used condoms for sex

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with casual partners in the 30 days after they were informed of their HIV status.3 In contrast to the high rate of condom use for sex with casual partners, only 19 per cent of the respondents said that they used condoms during sex with their spouses or regular partners in the same period. And quite a number of the men we interviewed in-depth conceded that they were much less inclined to use condoms in sex with their wives or regular partners than with prostitutes. This implies that these particular male respondents did not tell their steady partners that they had HIV and therefore were hesitant to use a condom because this act of sexual safety could suggest that they had an STI. Not using a condom was an attempt to prevent disharmony in treasured personal relationships, even when this could be interpreted as an act of dishonesty if that regular partner found out. It should not be forgotten that we are talking about these men’s HIV disclosure within the first month after their diagnosis, a period of time characterised by shock, agony, fear and uncertainty. They may have needed time to mull over the question of HIV disclosure, which is a hard thing to do under any circumstances ( Jing, 2006; Yoshioka, 2001). And given their own admission that they might have acquired HIV because they had paid for sex, disclosing the HIV test result to their wives and steady partners might be an even harder decision to make.

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Neglect of sexual safety In the Kaiyuan study, we found eight individuals who were extremely depressed in the first 30 days after their HIV diagnoses and engaged in unprotected sex knowing full well that it could infect others. Many Chinese health researchers and even social scientists would regard this kind of behaviour as an intentional act to harm other people. In Regulations for HIV/ AIDS Prevention and Control, enacted in early 2006 as China’s legal framework in dealing with the HIV epidemic, Articles 38 and 62 stipulate that intentional transmission of HIV, by whatever means, is a crime that must be punished according to China’s Criminal Law. But this key Chinese legal document on HIV does not discuss at all what constitutes intentional transmission. The question of whether or not the transmission of HIV via unprotected sex is intentional is thus left completely unanswered. A legal debate goes on within China with regard to this question. I have written elsewhere about my position on intentional HIV transmission (Sun Yongli, 2009). Here, I would like to argue that neglect of sexual safety after an HIV diagnosis is at least a form of personal irresponsibility. But this form of irresponsibility is related to particular situations and specific human relationships. Above all, it is associated with one’s history of unsafe sex and one’s state of mind after an HIVpositive diagnosis. Let me use two cases to explore this and also

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apply the principle of psycho-social distancing mentioned earlier. For the purpose of confidentiality, I have changed the personal names and other related information of the two individuals whose experiences make up the following cases. Case 1: Xiao Dong, age 45, discovered he had HIV when he received treatment for a high fever. He was an injecting drug user and had maintained a steady sexual relationship with a school teacher. After his HIV diagnosis, the school teacher broke up with him. Instead of believing that he might have got infected with HIV via his drug use, he blamed his former partner for his illness, even though he did not know for sure whether she was HIVpositive. After a stint at a detoxification centre, he got to know a middle-aged sex worker who was soliciting in a public square. At the beginning of their sexual relationship, he did not tell her that he had HIV and he wanted to see ‘if one year is enough to get a person infected with HIV’. But he soon became fond of her and decided to disclose his status. She did not mind and told him that she had been tested herself but the result was negative. She also told him that she had a minor form of syphilis. The two continued to have unprotected sex. In the meanwhile, he did not have sex with any other women. They lived as a couple, though she still worked as a prostitute. On a visit to her daughter, who was married and lived elsewhere, he told her daughter that he had HIV and suggested that she encourage her

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mother to take another HIV test. When the younger woman did so, her mother became angry. She felt that she had been shamed deeply by his revelation and suggestion. They quarrelled at her daughter’s home, leading to the breakup of their relationship. Xiao Dong’s neglect of sexual safety after his HIV diagnosis occurred in his initial sexual relationship with the sex worker. At this stage, he wanted to see if he could infect her with HIV through sex. But he grew fond of her and told her of his HIV status, which was an unmistakable indication that he wanted to protect her (through initiating condom use). Yet, the woman declined his offer. She had many other opportunities to be infected with HIV. In Kaiyuan and other Chinese cities, prostitutes working on the streets or in public squares constitute the lowest end of the sex trade in terms of the meagre amount of money they earn for each sexual transaction and in terms of a general lack of protection against physical violence from unsatisfied clients or criminals. Older sex workers, in particular, frequently have to deal with their clients’ demand not to use a condom. These clients tend to come from the lowest end of a stratified society in terms of their earning power, occupation or education. But in desperation to make money, older workers often have to comply with the demand for unprotected sexual intercourse by their clients ( Jing Jun, 2006). This might explain why the sex worker in Xiao Dong’s case had a very casual attitude to his HIV status. What she minded most, it seems,

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was Xiao Dong’s revelation of his HIV to her daughter. In her eyes, this was an entirely different matter, because it embarrassed her in the context of a mother-and-daughter relationship. It was not his HIV status that finally drove her away from him. Nor was it the unprotected sex they had until then. Rather, she broke up with him in anger over the unilateral disclosure of his HIV status to someone whose opinion about her as a mother meant a lot to her. Case 2: Ah Mei, age 25, was born in a rural family in Kaiyuan and had a history of drug use since she was a teenager. At 20, she worked in a string of cities as a sex worker and much of her income was spent on narcotics. In addition to having unsafe sex with her clients, she had unprotected sex with a series of boyfriends. A boyfriend in a small town bordering Vietnam was an alcoholic. Another boyfriend in Kaiyuan was a heroin addict. Unaware that she worked as a prostitute, a boyfriend in a larger city provided for her until he found out that she had other boyfriends in the same city. Back in Kaiyuan, she had a boyfriend who worked as security guard. He knew that she was working as a prostitute but he engaged in unprotected sex with her nonetheless. She broke up with the security guard after becoming sexually involved with ‘an oil company boyfriend’. He was married and knew that she was working in the sex trade. They had unprotected sex anyway.

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After Ah Mei was diagnosed with HIV, this boyfriend did not notice her dramatic change of mood. Although she did not tell him about her HIV status, she still resented his lack of sensitivity. In less than a month, she acquired ‘a water company boyfriend’ who supported her both emotionally and financially. However, she did not tell him about her HIV status either. She also lied to him about her occupation and continued to work as a prostitute in dance halls. She said that she once harboured the idea of deliberately passing HIV to men through sex because she thought she must have contracted it from one of the many men with whom she had had sex. She blamed these men for her HIV status and wanted to take her revenge against all promiscuous men she would encounter in the future. She gave up her idea of revenge because she was touched by her new boyfriend’s tender care. Yet, when this new boyfriend went on extended business trips, she felt lonely living by herself. ‘I am used to working in dance halls. Living alone is boring. So I sneaked out to work,’ she said. She also admitted that she did not have protected sex on these occasions if her clients did not like using condoms. With her new boyfriend, however, she insisted on using a condom even when he badly wanted to have unprotected sex with her. She was genuinely concerned about him. Another person she worried about was a woman. ‘When I was first diagnosed with HIV, I still had sex with the oil company boyfriend,’ Ah Mei said. ‘He and his wife are now on good terms with each other. I am afraid his wife will get it

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from him.’ Apart from some doctors, the only person in Kaiyuan who knew that Ah Mei had HIV was her older sister, also a sex worker and heroin addict, she said. She suspected that her sister had HIV too. This case highlights the close connection between women’s addiction to drugs and their resorting to sex work or to wealthy men to fund their addiction. Their dependency on paid sexual relations with men does not give women like Ah Mei much power to negotiate with men over the use of condoms. But after being diagnosed with HIV, Ah Mei had unprotected sex in only two situations. First, it occurred in her relationship with her ‘oil company boyfriend’ when she was still in shock after her HIV diagnosis. Second, it occurred in sex with her clients, when she was lonely while her boyfriend was on business trips. It seems that the temptation to earn extra money in the dance hall was too much for her to resist. Her experience of having worked in the sex trade since she was 20 had already shaped her beliefs about men’s attitude and behaviour when it came to the use of condoms in paid sexual intercourse, and once back in the sex trade, these beliefs were resurrected. Besides, these were men who were socially and emotionally distant from her world. Even if she wanted her clients to use condoms, she did not have the negotiating power to enforce it. Her lack of responsibility can be traced to a conditioned mindset at the individual level and a power balance that favoured her clients.

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Conclusion Many studies have shown that sexual practices change indirectly as a consequence of disclosing one’s HIV status to sexual partners. For example, Pinkerton and Galletly (2007) found that disclosure reduced the risk of HIV transmission by a range between 17.9 and 40.6 per cent compared with non-disclosure. Another example of how an HIV-positive diagnosis may indirectly inf luence sexual behaviour was explored by Bradley, Remien and Dolezal (2008) who found that HIV-positive people in serodiscordant relationships were less likely to engage in risk behaviour with their partners if they themselves were depressed. In this case, depression, which may have been a consequence of an HIV diagnosis, appears to have some positive bearing on sexual practice. In a study of men who have sex with men (MSM) in California, a large proportion of HIVpositive respondents said they disclosed their HIV status so as to have sex with people who were HIV positive as well (Patel et al., 2003). As is evident from these studies, changes in sexual behaviour following an HIV diagnosis are complex and should not be expected to be a natural outcome of a positive diagnosis. In the findings generated by the Kaiyuan study, I have tried to incorporate these complexities of sexual behaviour change after HIV diagnosis into my discussion. I have taken this a step further to ref lect social contexts and personal relationships. I have described the principle of psycho-social distancing

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whereby those who were close to the respondents, either because of affective relations or social attachments, were more likely to be informed of the respondent’s HIV status than those who were not. When it came to condom use the respondents were more likely to practise safe sex with casual partners than with spouses or steady partners. This should not be taken as a contradiction. Instead, it follows an identical logic with which the respondents made their decisions. On the one hand, they wanted to reveal their HIV status to those about whom they cared a lot. These were also individuals whom they could trust in the sharing of an extremely confidential matter. But that same closeness is also where condoms get discarded. The Kaiyuan study contains cases in which safe sex with one’s close partners was practised without HIV disclosure. On the other hand, the respondents wanted to protect themselves by using condoms in casual sex with those who are socially and emotionally distant from them. In these cases, HIV disclosure was a non-issue in the eyes of the respondents. Viewed in this light, the personal stories told by Xiao Dong and Ah Mei powerfully illustrate what I have described as ‘neglect of sexual safety’ because they show a complex array of human relations in which HIV disclosure or condom use either takes place or fails to occur. Both Xiao Dong and Ah Mei initially considered the idea of passing the virus to other people, and yet both changed their mind. In the case of Xiao Dong, he grew attached to a sex worker and gave up his idea of hurting

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her. In Ah Mei’s case, she abandoned her idea of taking revenge against promiscuous men once she had a new boyfriend whose caring behaviour touched her. As a sex worker, she continued to have unprotected sex with her clients. In that situation, her seemingly irresponsible actions should be viewed as the result of a hardened attitude on her part about what men want. Above all, in these instances she did not have much negotiating power. She could have refused unsafe sex but it would mean that she would lose her clients and hence her income. In sum, the Kaiyuan study shows that it is impossible to formulate a clear-cut judgment on HIV disclosure and condom use among HIV-positive individuals. In real life human relationships are so complex that a black-and-white perspective is not only misleading but also extremely unhelpful for HIV prevention. Even so, the respondents did not give up trying to at least consider who they should protect and why. And we must remember they were dealing with all this in the first month of their HIV diagnoses.

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References Bradley, Mark V., Remien, Robert H. & Dolezal, Curtis (2008), ‘Depression Symptoms and Sexual HIV Risk Behavior Among Sero­d iscordant Couples’, Psychosomatic Medicine, vol. 70, no. 2, pp. 186–191. Courtenay-Quirk, Cari et al. (2008), ‘Factors Associated with Sexual Risk Behavior among Persons Living with HIV: Gender and Sexual Identity Group Differences’, AIDS Behavior, vol. 12, no. 5, pp. 685–694. Jin, Xia et al. (2008), ‘Changes of HIV/AIDS testing strategy’ (Aizibing jiance celue de bianhua), China Journal Prevention Medicine (Zhonghua yufang yixue zazhi), vol. 42, no. 6, pp. 502–503. Jin, Xia et al. (2009), ‘Inf luence of HIV testing mode and notification on risk behaviors of injecting drug users in southern China’, Sexually Transmitted Diseases, vol. 36, no. 8, pp. 473–477. Jing, Jun (2005), ‘Surveillance of AIDS Epidemic in China’ (Zhongguo aizibing yiqing jiance zhuangkuang), Chinese Journal of AIDS & STD (Zhongguo aizibing xingbing), vol. 11, no. 6, pp. 446–448. Jing, Jun (2006), ‘Social Origins of AIDS Rumors: Moral Panic and Trust Crisis’ (Aizibing yaoyan de shehui genyuan), Journal of Social Sciences (Shehui kexue), no. 8, pp. 5–17. Jing, Jun (2006), ‘The Titanic Rule: A risk analysis of the HIV/AIDS epidemic in China’ (Taitannikedinglv: zhongguo aizibing fenxian fenxi), Sociological Research (Shehuixue yanjiu), no. 5, pp. 123–150. Liu, Li et al. (2007), ‘Analysis on the Status of HIV Antibody Testing in General Hospitals in Sichuan Province’ (Sichuan sheng zonghe yiyuan aizibing bingdu kangti jiance xianzhuang fenxi), Modern Preventive Medicine (Xiandai yufang yixue), vol. 34, no. 17, pp. 3356–3357. Ma, Yanmin (2006), ‘Strategy and Evaluation of HIV Screening’ (HIV shaicha celue jiqi pingjia), Chinese Journal of AIDS & STD (Zhongguo aizibing xingbing), vol. 12, no. 6, pp. 573–574. Marks, Gary (2006), ‘Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA’, AIDS, no. 20, pp. 1447–1450.

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Marks, Gary et al. (2005), ‘Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: Implications for HIV prevention programs’, Journal of Acquired Immune Deficiency Syndrome, vol. 39, no. 4, pp. 446–453. Patel, P. et al. (2003), Circuit parties: Sexual behaviors and HIV disclosure practices among men who have sex with men at the White Party, Palm Springs, California, 2003, AIDS Care vol. 18, no. 8, Nov 2006, pp. 1046–1049. Pinkerton, Steven D. & Galletly, Carol L. (2007), ‘Reducing HIV Transmission Risk by Increasing Serostatus Disclosure: A Mathematical Modeling Analysis’, AIDS and Behavior, vol. 11, no. 5, pp. 698–705. Rawstorne, Patrick et al. (2007), ‘Differences between HIV-positive gay men who “frequently”, “sometimes” or “never” engage in unprotected anal intercourse with serononconcordant casual partners’, Positive Health Cohort, Australia, AIDS Care, vol. 19, no. 4, pp. 514–522. Sarit, A. et al. (2008), ‘Determinants of High-Risk Sexual Behavior during Post-Exposure Prophylaxis to Prevent HIV Infection’, AIDS Behavior, no. 12, pp. 852–859. Sun, Yongli et al. (2009), ‘Investigation and Consideration on Intentional Transmission of HIV/AIDS’ (Guanyu guyi chuanbo aizibing xingwei de diaocha yu sikao), Medicine and Philosophy (Yixue yu zhexue), vol. 30, no. 4, pp. 36–38. Wang, Haibo et al. (2007), ‘Prevalence and risk factors associated with HIV infection among Female Sex Workers in a county of Yunnan province’ (Yunnansheng moushi nvxing xinggongzuozhe HIV ganran jiqi weixian yinsu diaocha), Chinese Journal of AIDS & STD (Zhongguo aizibing xingbing).vol. 13, no. 3, pp. 220–223. Yang, Hong et al. (2005), ‘Heterosexual transmission of HIV in China: a systematic review of behavioral studies in the past two decades’ (HIV zai zhongguo yixing jian de chuanbo: guoqu ershi nian xitong yanjiu zhi huigu), Sexually Transmitted Diseases (Xing chuanbo jibing), vol. 32, no. 5, pp. 270–280.

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Yoshioka, Marianne R. & Schustack, Amy (2001), ‘Disclosure of HIV Status: Cultural Issues of Asian Patients’, AIDS Patient Care and STDs, vol. 15, no. 2, pp. 77–82. Zhao, Rui et al. (2005), ‘Sexually transmitted disease/HIV and heterosexual risk among miners in townships of Yunnan Province, China’ (Zhongguo Yunnan xiangzhen meikuang xingchuanbo jibing/HIV he yixing zhijian de fengxian), AIDS Patient Care and STDs (Aizinbing he xingchuanbo jibing bingren huli), vol. 19, no. 12, pp. 848–852. Zheng, Zhenyu et al. (2007), ‘The application of HIV testing policy in regulatory sites’ ( Jianguan changsuo zhong aizibing jiance zhengce de yingyong), Chinese Journal of AIDS & STD (Zhongguo aizibing xingbing), vol. 13, no. 6, pp. 595–597.

Notes 1 When the HIV epidemic began attracting serious government attention in China in 2003, the country’s tally of confirmed HIV cases was 30,000. By late 2009, a total of 320,000 confirmed cases were accumulated. The rapid increase of confirmed HIV cases does not necessarily mean that China’s HIV epidemic became worse. Instead, it simply means that the government scaled up HIV testing by offering it not only in cities but also in rural areas, particularly in regions where a higher-than-usual HIV prevalence has been found. These include Yunnan, Guanxi, Sichuan, Guangdong, Henan and Xinjiang. Each had more than 20,000 confirmed cases by the middle of 2009. 2 Kaiyuan is a multi-ethnic city in the southeast of Yunnan province. It has nearly 30 million registered residents. The Yi, Miao, Hui and Zhuang, together with 33 other smaller ethnic groups, account for 51.9 per cent of Kaiyuan’s total population. 3 The cut-off point of 30 days before and after an HIV diagnosis was one of the decisions we made in preparations for the Kaiyuan study, because we believed that it would be easier for our respondents to recall their reactions to their HIV diagnoses when the time frame was specified.

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7 The Central Place of the Chinese Family in HIV Narratives He Mingjie

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his chapter explores how people living with HIV in China perceive and describe their HIV status in relation to their work, their communities and, in particular, their families. The basis of my analysis is an AIDS Oral History Project organised by the AIDS Policy Research Centre at Tsinghua University in Beijing, which has collected a total of 71 personal narratives on HIV. Gathered from five cities and many more rural communities in four provinces, these narratives form a rich and valuable source of information about how people react to the discovery that they have HIV; what concerns they had in trying to obtain medical assistance; the point at which they revealed their HIV-positive status to their families, and why some of these individuals suffered a severe degree of familial discrimination. Family relationships, in general, constitute a set of complex dynamics that directly affects the quality of life among people infected with HIV. The Chinese family can be a source of tender care under most circumstances, including its encounter with HIV. However, it can also be a source of great aff liction. This chapter describes the reactions of some of the Chinese families whose loved ones have been infected with HIV.

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An oral history project The AIDS Oral History Project at Tsinghua University started in 2003, and by 2007 had collected personal narratives from 58 men and 13 women. These narratives were obtained through semi-structured interviews focusing on issues such as: • how the respondents had acquired HIV • when they learned about their HIV-positive status • what concerns they had in dealing with their status • where they found social support if needed. Among our respondents, 35 were male homosexuals and 31 were farmers who had sold blood as a way to generate an extra income. Only four people had acquired HIV through heterosexual sex or through injecting drug use. One woman’s HIV status was caused by a contaminated blood transfusion. A number of researchers who either taught or studied at Tsinghua University gathered these narratives. Led by Professor Jing Jun, the Director of the AIDS Policy Research Centre, this research team included: Zhang Hui, now a PhD student at the London School of Economics; Su Chunyan, now a lecturer at Beijing Youth College of Political Science; Zhang Yuping, now a PhD candidate at Tsinghua University; and Yu Jing, now a lecturer at the Central University of Finance and Economics. I participated in this project in 2007 by interviewing six HIVpositive individuals in the city of Chengdu. The interviews that generated the narratives I am about to analyse usually

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lasted for more than one hour. They were tape-recorded and then transcribed. Information that may expose the identities of the interviewees has been altered to ensure confidentiality, but such alterations do not affect the analysis that follows. Everyone who worked on the AIDS Oral History Project at Tsinghua University was convinced that research into people living with HIV in China badly needed an ‘emic’ approach that would value personal accounts of behaviour, experience or beliefs in terms meaningful to the individuals whom we study. These accounts might be extremely subjective, personal and even challenging to our expectations of objectivity, but they constitute a voice of the people we try to understand, a voice that reveals their feelings and their views toward what is at stake for them in an HIV-positive diagnosis. Social and behavioural research on HIV in China and many parts of the world has been routinely conducted from the perspective that regards so-called ‘most-at-risk populations’ and HIV-positive individuals as a problem for public health. In that paradigm, people’s attitudes, knowledge and behaviour are studied as a source of risk that poses a threat to general populations (Bor et al., 1993; Zhang, 2002; Qu et al., 2002). The AIDS Oral History Project was launched and undertaken to challenge this risk-oriented approach. The project has contributed to the completion of a postgraduate thesis, a doctoral thesis, a series of journal articles, and a collection of personal testimonies presented at two public hearings at which sensitive issues of

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testing, treatment, social assistance and the legal rights of people suffering from HIV or AIDS were discussed.

Family reactions to critical experiences From the information generated by the AIDS Oral History Project I noticed that there were three stages during which each respondent had critical incidents that changed their life in a fundamental way. The first stage was when they were tested positive. The test result often came as a shock to the respondents, even though some had suspected that it would be positive. Because of their ignorance of HIV and the forms of treatment, all 71 individuals said that their distress upon the discovery of their positive status was followed by tremendous fear. They feared most that their disease could not be controlled and that they would die very soon. The second stage was their struggle to come to terms with their diagnosis once they had acquired some medical knowledge about HIV and had realised that the treatment could prolong their life. At this stage, their will to live replaced their shock and fear of death. But other fears soon took over, mostly about their ability to continue to work, to pay for treatment, and the possibility of people finding out that they were HIV-positive.

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The third stage was their attempt to reorganise their lives so they could lead a normal life. At this stage, they were preoccupied with finding solutions to economic security and keeping their status a secret. Some told their families about their HIV status or at least considered the pros and cons of doing so. Throughout these three stages, concerns about their families persisted. The typical question they asked themselves on discovering that they had HIV was ‘if I die, what will my family do?’ For the majority of the 71 respondents, the test results caused distress, numbness, anger and sadness. No matter how they became infected with HIV, these individuals experienced severe shock after being diagnosed with HIV (Ezzy, 2001) and, among other things, this led to thoughts of their family. For many, this was the first time they understood the fragility of life. For example, in talking about his reactions to the positive test result, a 27-year-old gay man said: ‘I felt blank. I couldn’t think. I couldn’t feel anything. I thought the result must be wrong. I wanted it to be checked again. I called the authorities at my school for a leave of absence. I stayed in my room for three days. I cried and cried. I thought it was unfair. I’m not a bad person. Why have I caught this disease? What can I do? If I died, what will my family do?’ The fear of death was accompanied by a deep sense of shame. Even those who had acquired HIV via the blood supply system (which means that they did not engage in what is considered in Chinese society as immoral behaviour) also felt this shame.

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One source of their sense of shame was the Chinese news media. From the mid-1980s to the mid-1990s, the Chinese news media portrayed HIV as a disease of decadent Westerners and immoral Chinese. A 40-year-old nurse who became infected as the result of a medical accident, revealed how she once linked HIV, immorality and Westerners together: ‘I knew it is infectious. I used to think it was far away from my life. I read about it in news articles and on radio. It was described as a disease of foreigners, especially Westerners. But I never thought I would have this disease.’ Although the connection to Westerners was no longer emphasised in the news media when many Chinese citizens were found to be infected by HIV by the late 1990s, the news reports still used scare tactics, portraying the disease as having horrifying consequences to the human body. A 46-yearold gay man said, ‘News articles on HIV show ugly pictures of AIDS patients so as to scare people. These pictures are intended to warn people who have high-risk behaviours. Pictures of normal AIDS patients are never published.’ For many of the respondents the sense of shame went beyond the confines of individuality, because public knowledge of their HIV status would bring shame on their family. So in their personal narratives about the second and third stages of their critical experiences, they spoke frequently of the desire to honour their families and yet found it hard to do so since their HIV status (still secret) was a potential source of disgrace for their families. ‘I cried and was scared. Then I thought my life

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is over but I also thought of my parents,’ a gay man in his early 30s recalled. ‘I wanted to kill myself at one point. But I thought of my mother and decided not to let her down.’ Keeping their HIV status secret from their families was common among the urban gay men who were unmarried. In the eyes of these men, the disclosure would shock and sadden their parents for two reasons. First, their homosexuality would be uncovered, and homosexuality is much stigmatised in Chinese society and very little understood by their parents ( Jones, 1999). Second, if they were publicly known to have HIV, they may face discrimination from outsiders (Li et al., 2007). As well, they would be likely to face an emotional reaction from their parents or siblings. However, among those farmers who had sold their blood and consequently become infected with HIV, the secret of their HIV status could be and was often shared within the family. The secret, however, must be guarded within their village, unless the village had a cluster of HIV infections affecting many families. In that case, it was possible, said some of the rural respondents, to form an alliance of mutual support on the basis of shared emotions in facing a common tragedy. According to those who revealed their HIV diagnosis to their families, support was usually provided by their parents and siblings. Family support was described as the function of improving the quality of care and treatment (Bor et al., 1993; Peguegnat et al., 2001; Li et al., 2009), and this applied to a handful of gay men who informed their families of their HIV

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status. In most cases, the family served as a supervisory force by urging them to comply with the requirements of medical treatment. In rural communities where clustered HIV infections were found, family support seemed to be a key in determining if a person could rise above his or her health problems and even lend a hand to other people living with HIV. This is how a 40-year-old farmer described this possible transformation: ‘My wife, my brother and sister now all know about my illness. They support me and I feel warm. In the beginning, they could not handle it. Gradually, they faced it squarely. I often take HIV brochures home. They have come to know what HIV is and how to prevent it. We are getting along well. Because of this, I want to help those people who have the same disease.’ This farmer was referring to his fellow villagers who also became infected by HIV through trade in blood in the early 1990s. However, HIV can reshape family dynamics with devas­ tating consequences (Peguegnat et al., 2001; Li et al., 2009). This occurred in the case of a woman we interviewed. She was infected with HIV through a blood transfusion and was diagnosed only when she developed AIDS-related symptoms. The hospital responsible for the botched blood transfusion refused to acknowledge responsibility. This woman had medical insurance through her work, but she did not dare to ask for her medical bills to be reimbursed because she was afraid that she would be fired from work due to her HIV status. She decided

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to seek medical treatment secretly and cover the expenses out of her pocket. Her distress due to these already serious troubles was made even worse when she told her family of her HIV status. She was soon unjustly accused by her mother-in-law of having engaged in extramarital affairs. Her mother-in-law, however, believed that she had HIV because she was promiscuous. Her husband, while not believing that she had been unfaithful to him, rejected her nonetheless, not allowing her to cook for their child and eventually taking the child away to live elsewhere. She begged her husband to let her see her child – but he would not yield. Her plight was made worse when her mother-in-law started publicly calling her a slut. As a result, her neighbours began keeping their distance from her.

Family and HIV At the beginning of this chapter, I outlined three stages of lifechanging experiences for a number of people living with HIV in China. The first stage was when they were tested positive for HIV, and this stage was characterised by shock and fear of death. The second stage was the coming to terms with their positive diagnosis, and their common experience was a combination of anxieties, mostly regarding work, medical expenses and identity exposure. The third stage was their attempt to lead a normal life by finding solutions to economic security, either keeping their HIV a secret, or managing the

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consequences of revealing their status to their families. The diagnosis stage was the most traumatic stage for these people, as they were abruptly forced to face what they considered at first to be the end of their lives. In addition, they worried about the impact of their diagnosis on their families (Zhou, 2007). They anxiously debated with themselves whether or not they should inform their families of their HIV status and were gravely concerned about the reaction from within their family. Most of the gay men decided not to tell their families. For those farmers who became infected by HIV through the once-rampant trade in blood, telling their families was relatively easy, but they still needed to guard the secret in rural communities where HIV was not commonly known. These respondents articulated clearly that the Chinese family was the heart and centre of their personal life. They shared the belief that their families were a cornerstone of their existence, even when they were no longer living with them. On the one hand, the decision not to tell their families was based on their determination not to bring shame down upon them. On the other hand, the decision to tell their families was to seek help in terms of emotional and practical support. However, the ultimate and also the minimum degree of help they sought from their families was that of understanding. In those families that eventually knew the HIV status of their loved ones, parental, conjugal and kinship support seemed to have directly enhanced their will to cope with the disease

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and come to terms with its consequences. In an overwhelming number of cases, family support was offered. Social scientists have long regarded Chinese families as a cushion against external shocks (Li et al., 2009). For example, Chinese social research on unemployment, old-age support and patient care shows that the Chinese family is a de facto welfare agency as much of what should be done by state agencies falls to the family (He, 2006; Mei et al., 2005; Tang, 2007). Therefore, when an adult child becomes unemployed, financial support will come from the parents. If the parents are unable to do so, siblings will contribute to his or her welfare. As for old-age support, government’s help in this is minimal, so the family takes over. Patient care also demonstrates the centrality of the Chinese family. Once hospitalised, a patient’s kin take turns in acting as nurses. They even move into the hospital to live with their loved one, sometimes for as long as a few months. So family reaction can be both positive and negative. Earlier, I discussed the woman who was persecuted at the hands of her mother-in-law and her husband. Her experience reminds us of the complexity of family relations in a culture that places a special value on familial harmony (Zhou, 2008). In short, their family provided a conceptual framework for these respondents to perceive the social meanings of HIV. The Chinese family occupies a central place in the ways in which HIV is interpreted by these individuals.

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References Bor, Robert, Millert, Riva, Goldrnan, Eleanor (1993), ‘HIV/AIDS and the Family: A Review of Research in the First Decade’, Journal of Family Therapy, vol. 15, no. 2, pp. 187–204. Ezzy, Douglas (2001), ‘The AIDS Crisis and the Modern Self: Biographical Self-Construction in the Awareness of Finitude’, Contemporary Sociology, vol. 30, no. 5, pp. 528–529. He, Mingjie (2006) ‘Using Cultural Perspectives to Understand Families Covered by the Minimum Standard of Living Policy’ (Wenhua Toujing Xia De Dibao Jiating), China National Conditions and Strength (Zhongguo Guoqing Guoli), no. 5, pp. 35–37. Jones, Rodney (1999), ‘Mediated Action and Sexual Risk: Searching for ‘Culture’ in Discourses of Homosexuality and AIDS Prevention in China’, Culture, Health and Sexuality, vol. 1, no. 2, pp. 161–180. Li, Li, et al. (2007), ‘Disclosure of HIV Status is a Family Matter: Field Notes from China’, Journal of Family Psychology, vol. 21, no. 2, pp. 307–314. Li, Li et al. (2009), ‘Parents Living with HIV in China: Family Functioning and Quality of Life’, Journal of Child and Family Studies, vol. 18, no. 1, pp. 93–101. Mei, Jianming, Qin, Ying (2005), ‘A Review on Urban Poverty and Anti Poverty Strategy in China’ (Zhongguo Chengshi Pinkun Yu Fanpinkun Wenti Yanjiu Pingshu), Population Science of China (Zhongguo Renkou Kexue), no. 1, pp. 88–94. Pequegnat, Willo, Bauman, Laurie & Bray, James et al. (2001), ‘Measurement of the Role of Families in Prevention and Adaptation to HIV/AIDS’, AIDS and Behavior, vol. 5, no. 2, pp. 1–19. Qu, Shuquan, Zhang, Wei (2002), ‘AIDS Epidemic Situation in Asia and Pacific Areas’ (Yatai Diqu Aizibing De Liuxing Qushi), Disease Surveillance ( Jibing Jiance), vol. 17, no. 7, pp. 280–282. Rosenthal, Elizabeth (2000), ‘Chinese Media Suddenly Focus on a Growing AIDS Problem’, New York Times, 17 December, p. 16.

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Tang, Yong (2007), ‘A Literature Review and Investigation of Concept ‘‘Filial Piety’’’(Xiaowenhua De Wenxian Zongshu Yu Xiaoguannian De Diaocha), Journal of Social Work (Shehui Gongzuo), no. 1, pp. 23–25. Zhang, Konglai (2002), ‘Review: Epidemic Rules and Trends of AIDS in Asia and China’ (Aizibing Zai Yazhou Ji Woguo De Liuxing Guilu He Qushi), Chinese Edition of British Medical Journal (Yingguo Yixue Zazhi Zhongwenban), vol. 5, no. 1, pp. 38–39. Zhou, Yanqiu Rachel (2007), ‘‘‘If You Get AIDS, You Have to Endure It Alone’’: Understanding the Social Constructions of HIV/AIDS in China’, Social Science & Medicine, vol. 65, no. 2, pp. 284–295. Zhou, Yanqiu Rachel (2008), ‘Endangered Womanhood: Women’s Experiences with HIV/AIDS in China’, Qualitative Health Research, vol. 18, no. 8, pp. 1115–1126.

Notes 1 Two legislative hearings on HIV were held at Tsinghua University in 2002 and 2005 to discuss human rights, public policy, and issues of testing. Participants in these hearings included social scientists, medical doctors, lawyers, and people living with HIV/AIDS as well as reporters. I took part in both hearings as a conference assistant. 2 HIV infections among farmers in central China due to trade in blood first became known to the Chinese news media when Zhang Jicheng wrote about it in the West China Urban Newspaper on 18 January 2000. However, Zhang Jicheng’s story failed to stir up the Chinese news media’s coverage of the HIV epidemic in central China, not until the New York Times published two detailed and highly critical news stories, one on 2 August and one on 28 October 2000. These reports provoked a f lood of investigative reports in the Chinese press about the role of the blood trade in the Henan HIV epidemic. The Chinese news media’s sudden focus on HIV in central China was reported in the New York Times as well (see Rosenthal, 17 December 2000).

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8 Stigma and HIV Discourse in China Zhang Youchun

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IV is so highly stigmatised worldwide that the stigma attached to it has long been regarded as an epidemic in itself (Herek & Glunt, 1988). Although anti-stigma campaigns have been waged in many countries affected by the HIV epidemic, stigma continues to thrive (Fogarty International Center, 2001). As a prominent figure in HIV once pointed out, stigma imposes a major roadblock for developing effective HIV care and treatment services throughout the world (Piot, 2002). That assessment remains valid today, because one of the many manifestations of stigma is the reluctance of individuals to receive HIV testing or disclose their HIV status, thereby impairing the efficacy of health services. China suffers from similar problems due to stigma. In a survey of 2,000 people living with HIV in China, it was found that 87 per cent of the female respondents and 79 per cent of the male respondents identified gossip-based discrimination against them as a major concern if their HIV status was exposed (UNAIDS & Partners, 2009:9–10). In a study conducted by the United Nations Population Fund (UNFPA) among 2,500 young Chinese, 60 per cent of the respondents held the view that people living with HIV should be isolated from society (UNFPA, 2006:3–4). Ref lecting this attitude, Chinese local

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legislators have proposed that people living with HIV should be banned from public swimming pools and bathhouses.1 Chinese people living with HIV often lose their jobs once their HIV status is exposed. An additional consequence of identity exposure is that the children of HIV-positive people are often bullied and discriminated against at school.

International perspectives on stigma Any discussion of stigma should be underpinned by Erving Goffman’s inf luential work that defines stigma as a ‘significantly discrediting’ attribute, an attribute not only making the person ‘different from others’ but also ‘of a less desirable kind’ (Goffman, 1963:1–3). Goffman applied this concept of stigma to conditions, attributes or behaviours that mark the bearer of stigma as ‘culturally unacceptable’ or inferior, with consequent feelings of shame, guilt and disgrace. He further distinguished between three types of stigmas: the ‘abominations of the body’ such as physical deformities; the ‘blemishes of individual character’ such as mental illness, drug addiction and homosexuality; and the ‘tribal stigma’ such as bias built on attitudes about race, nationality and religion (Goffman, 1963:4–5). During the four decades following the publication of Goffman’s work on stigma, social scientists have examined a

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range of stigmatised circumstances, particularly in relation to illness such as leprosy (Opala & Boillot, 1996), mental illness (Corrigan & Penn, 1999; Phelan et al. 2000; Beech, 2003), deformity (Cahill & Eggleston, 1995) and HIV (Herek & Glunt, 1988; Farmer, 1992). Two outstanding problems associated with stigma studies are worthy of our attention here. First, they are often based on the perceptions and attitudes of those who stigmatise other people rather than the lived experiences and perceptions of those who are stigmatised (Link & Phelan, 2001). Second, the concept of stigma is vaguely defined and too often applied to individuals, while giving little attention to the social-cultural contexts and processes that shape individual realities (Das, 2001; Link & Phelan, 2001). In response to these criticisms, Link and Phelan reconceptualise stigma by defining its five interrelated components (Link & Phelan, 2001:363–76): • labelling – human differences are distinguished and labelled • stereotyping – the labelled individuals are linked to negative stereotypes • separation – the negatively stereotyped kind of persons are separated off as ‘them’ versus ‘us’ • status loss and discrimination – the labelled individuals encounter blocks to the realisation of life chances such as in education, employment, housing and marriage • exercise of power – ‘Stigma is entirely dependent on

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social, economic, and political power - it takes power to stigmatize’ (Link & Phelan, 2001:375). Link and Phelan further suggest that a form of ‘structural stigma’ also exists. The term refers to the institutionalised conditions such as policies and social routines that lead to the disadvantage of the stigmatised persons. In addition, Link and Phelan called attention to ‘internalized stigma’, which implies that the stigmatised person eventually comes to accept the discriminatory behaviours of others and the dominant view of their lower status.

Studies of HIV stigma in China In China, HIV-related stigma and discrimination have attracted attention from government and academic institutions. Chinese epidemiologists tend to rely on the imported KABP tool (i.e., a measurement of knowledge, attitude, behaviour and practice) as the starting point of their research. Their findings suggest that fear (Cao et al., 2006), misconceptions (Qian, Wang, Dong et al., 2007), and moralisation (Lee, Wu et al., 2005) are the main sources of HIV stigma. Social scientists, on the other hand, take a different approach. They tend to understand stigma as a socio-cultural construction of HIV’s meanings which in itself is a con­sequence of values and beliefs (Weng, 2001; Jing, 2006). Some Chinese scholars have also used the perspective of human rights and medical ethics (Qiu, 2001) to study HIV

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stigma. One of the most important findings of these studies is that people living with HIV are perceived by the public in two totally opposing ways. On the one side, injecting drug users and sex workers living with HIV are said to suffer from stigma mainly because of beliefs about their ‘immoral and illegal conduct’. On the other, those who have been infected via blood donation, blood transfusion and mother-to-child transmission are seen as ‘innocent victims’, so any stigma directed at these groups is the fear generated by a lack of understanding about how HIV is transmitted. As a number of Chinese scholars have pointed out, public opinion dividing HIV-positive people into innocent versus immoral victims is derived from multiple political and social forces (Weng, 2001; Zhang Hui, 2004; Zhang Youchun & Li Xiaolin, 2005; Jing, 2006; Pan, Huang & Li, 2006). To begin with, in the 1980s the Chinese government believed HIV was a disease typical of decadent Western lifestyles found in capitalist societies. As China started to witness an increase in confirmed HIV cases in the 1990s, the government branded HIV a purely sexually transmitted infection (STI), casting a powerful spell on public imagination about the specific route of HIV transmission. By the early 2000s, however, tens of thousands of ordinary farmers in central China who had sold their blood to make a living were found to be HIV-positive. At this point, the government’s tone changed from denunciation to reconciliation. It became clear that HIV in China was transmitted, in part, via

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trade in blood as well as blood transfusion at public hospitals. Since the direct responsibility for safeguarding the vitally important supply of blood for medical use was that of the state, Chinese authorities decided to launch an antiretroviral treatment program in those rural areas hit hardest by a oncerampant trade in blood. The program was launched despite the fact that only five antiretroviral drugs were available in China, barely enough to put together first-line therapy. At this moment, the government’s attitude to people living with HIV under­ went a conceptual shift. A new category – the innocent victim – was added to the official rhetoric on HIV. If we were persuaded by social thinkers on totalitarianism, we probably would come to the conclusion that public perceptions in China about HIV are dictated by a powerful state in a top-down manner. The reality is much more complex. The Chinese news media and the country’s medical establishment have had much to say about HIV too, and their opinions carry sway over state authorities as well as ordinary citizens. What follows is an analysis of the contributions of these two groups to the creation and continuation of HIV stigma in China.

The media and HIV stigma The role of the news media in shaping public opinions on HIV is recognised worldwide. But China has a blind faith about the ability of the media to reduce HIV stigma. We are told by

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veteran researchers on the Chinese news media that HIV stigma is derived from a general lack of medical knowledge and therefore the major role to be played by the news media is to educate the public (see e.g., Li & Zhou, 2005). The assumption is that HIV stigma declines when the level of knowledge about the virus among the public increases. This is precisely the staple of HIV education in China. But it is overly optimistic. The widespread HIV stigma among medical practitioners, for example, indicates that amassing a body of knowledge about HIV does not necessarily help eradicate stigma. At its best, the assumption that more medical knowledge leads to less stigmatisation is a fantasy of scientism. At its worst, the assumption ignores the forces of what Link and Phelan have described as ‘structural stigma’ – the overwhelming impact of institutionalised discrimination via policies and laws. In retrospect, the Chinese news media has paid a great deal of attention to HIV since its onset. In 1985, an American sought treatment for a medical condition in Beijing and was found to be HIV-positive through a blood test. This was the first HIV case found in China. Following this, more than 20 reports on HIV were published in the People’s Daily, the media arm of the Central Committee of the Communist Party of China. With a circulation of three million, the newspaper provides information on the policies and viewpoints of the Chinese state. In one of the reports, HIV was described as a ‘super cancer’ in Western countries that could be transmitted via such means as sharing a

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towel or a washbasin (Ma & Fan, 1985). The first wave of reports in the People’s Daily set the tone for reporting on HIV by identifying it as a disease of Westerners and as a communicable cancer. By the late 1980s, HIV was no longer portrayed in the Chinese press as a disease of Westerners since many Chinese people, mostly sex workers and injecting drug users, had also been diagnosed with HIV. The media then adopted the phrase ‘Western capitalist lifestyle’ in reference to how people became infected with HIV. Now the labelling effect started to work, since two concrete groups of Chinese individuals easily fell into the negative stereotypes of a common label (Pan, 2001). By the early 1990s, HIV cases were detected one after the other in the seaboard areas of China. Medical practitioners in these areas dealt with HIV-positive people as if they were a virus in themselves. They either refused to treat patients or wore gowns and masks when meeting patients, as if the virus could be transmitted by air or simple bodily contact. The grossly over-protective conduct on the part of medical practitioners did not escape the media’s attention, and it was reported as a necessary measure of protection against a highly infectious disease. At the same time, HIV was used as a warning in the Chinese news media against a changing public attitude towards sex. Compared with the Maoist era from the early 1950s to late 1970s when sex was the instrument of human reproduction, the 1980s and 1990s saw a surge of new opinions about sex,

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especially among younger people who looked on it from the perspectives of pleasure, intimate relationship and personal freedom. Trying to prevent what potentially was a sexual revolution, the news media went on a campaign to demonise HIV by linking sexual ethics with the sexual route of HIV transmission. In the early 2000s, however, an HIV epidemic was revealed among farmers who had sold blood and plasma in central China. This HIV outbreak seriously challenged the media’s depiction of HIV in association with immorality. Now a true tragedy could be reported, as the victims were no longer morally defective human beings. The label ‘innocent victims’ was coined. In this connection, sensationalising terms such as AIDS orphans, AIDS villages, AIDS mothers were employed to dramatise the suffering of ‘innocent victims’. From a time when literally not a single person living with HIV appeared on television, ‘innocent victims’ of HIV were invited to give televised interviews. But the media did not anticipate the terrible discrimination that would fall upon those who appeared in the media, despite the ‘innocent’ label used by reporters. A case in point was the experience of Xiao Wei and Lao Ji. In 2004, just one day before International AIDS Day, Chinese President Hu Jintao visited You An Hospital in Beijing where he shook hands with Xiao Wei and Lao Ji, two former plasma donors living with HIV. A brief conversation followed in which Hu encouraged these men to get well and told them that the

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Party, the State and all of Chinese society were supporting them. On International AIDS Day and during the week that followed, Hu’s meeting with Xiao Wei and Lao Ji was showed on television time and again.2 Soon, Xiao Wei’s wife called him from home to say that the cadres of the village where they lived wanted to evict the family. The reason was Xiao Wei had HIV and other villagers were afraid. His family eventually moved out of the village under pressure. They found a place to live in a rural county seat. Lao Ji’s family, also in a rural village, experienced similar discrimination. His appearance on television exposed his HIV status which he had kept secret until then. His son and daughter were immediately shunned at school. His wife was barred from every home in the village. His neighbours would not even allow the chicken his wife had raised to wander out from the yard of his home, because they were afraid that it, too, was infected. In both cases, the villagers knew that Xiao Wei and Lao Ji were innocent victims and yet the seemingly sympathetic label in the official and media discourse on HIV morphed into a completely opposite social reaction. Instead of sympathy, they met with hostility. Even President Hu’s handshake did not convince their neighbours that they should not be afraid and that they should be supportive.

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Medical establishments and HIV stigma Susan Sontag once suggested that the metaphor of disease can easily be used as a tool for social mobilisation or political persecution, thus leading to negative consequences (Sontag, 1978). The Chinese medical community uses a mixture of disease and war metaphors when describing the cause and effect of the virus. In this context, examples of war metaphors describing HIV include ‘life killer’, ‘invader in human immune system’ and ‘defence system’. War metaphors about people at risk or living with HIV include such terms as ‘target groups’, ‘high prevalence zone’ and ‘bridge population’. Some of these terms are internationally adopted in the field of public health. Once translated into Chinese, they sound even more menacing. When the term ‘high-risk group’ is translated into Chinese, for example, it literally means ‘highly dangerous group’. It no longer refers to a category of individuals who are vulnerable to HIV but a group of individuals whose very existence is dangerous to the general public. The change of emphasis is significant in that it ref lects how the medical establishment thinks about people at risk – as a threat to the public. The Chinese medical establishment’s attitude toward HIV is highly contradictory. On one hand, it must deal with the disease as a health problem rather than a moral problem. On the other hand, the close connection between HIV and sexual

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conduct and injecting drug use inevitably makes it a moral problem, even to health workers. This contradiction is manifested in the tensions between policies and laws that protect HIV-positive people’s legal rights, and the medical establishment’s view that these people are a threat to public health. According to a former health minister, any laws regarding HIV at the national level have two functions. First, the basic rights of HIV-positive individuals, including spouses and children, must be protected. Second, the potential harm that these people may cause to society must be taken into legal considerations and therefore legal restrictions on their conduct must be set, extending from behavioural change to medical compliance (Zhang Wenkang, 1996). The Chinese medical establishment must make both functions work since it has the duty to protect patients’ rights and set behavioural restrictions to make HIV-positive people comply with various rules of public health. Of these two functions, the medical establishment is more concerned with the second one and often issues directives aimed to serve the public’s interest by making HIVpositive people observe tough and sometimes even unrealistic regulations. A recent example of unrealistic regulations is an executive order issued in November 2009 by the Health Bureau of Gansu province in northwest China. By this order, all individuals who tested HIV-positive in Gansu must inform their spouses or sex partners of the test result within 30 days. And the disclosure

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must be face-to-face, followed by HIV testing on the part of those spouses or partners. If an individual does not comply with the order and has unprotected sex with his or her partners, the action would be interpreted as ‘intentional HIV transmission’, a category of irresponsible behaviour punishable under China’s civil law. And if the virus is indeed transmitted, the individual will face punishment under the country’s criminal law ( Jin, 2009). The order by Gansu’s provincial health bureau was China’s first clearly defined HIV disclosure regulation. Prior to this order, disclosure was neither mandatory nor criminalised. One serious problem associated with this form of mandatory HIV disclosure is its unrealistic nature. As Sun Yongli (chapter 6) and He Mingjie (chapter 7) show, HIV-positive individuals in China are reluctant to inform their spouses or steady partners of their HIV status immediately after the test results. Some will keep the result secret for a long time. Their intention not to disclose their HIV status has more to do with their mental state characterised by fear of death, shock and despair than with an intention to harm. They also need time to figure out if their spouses or partners can handle the bad news. Another serious problem of mandatory HIV disclosure is that the intended benefit for the general public depends on criminalising people’s failure to disclose their HIV status to their spouses or partners. The mandatory HIV disclosure requirement sends out a demonising message to the public, namely that these people are

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selfish or morally corrupt and hence they need to be reminded of the legal consequences if they fail to protect other people.

Conclusion: A key to dominant HIV discourse In public health terms, China’s HIV epidemic is said to have had three distinctive drivers – sex, drugs and blood trade. An argument can be made that stigma is also a powerful driver of the country’s HIV epidemic. This is because societal discrimination via denial of employment, residence, education and welfare, as well as personal fear of isolation, ridicule and helplessness combine into a formidable force of deterrence. Thus, people living with HIV become afraid to adopt prevention and treatment strategies, including regular health examinations, disclosure of a positive test result to intimate partners, access to antiretroviral treatment, or getting support within one’s family or community. Because the powerful discourse on HIV in the Chinese medical establishment and news media has created a series of negative images about people living with HV, an urgent task in dealing with stigma is the necessity to change the dominant discourse first. The public’s fear of acquiring HIV through everyday contact with people living with HIV can be reversed through scientific education, and yet moralising judgment on HIV is hardly a matter of science. Reduction of

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stigma associated with the public’s tendency to see HIV in moral terms hinges on a fundamental change of attitude in the Chinese news media and the country’s medical establishment. They hold the key to the dominant discourse on HIV. For this discourse to change, the news media and the medical establishment must stop taking a moral standpoint.

References Beech, Hannah (2003), ‘Stigmatized, Abandoned, Often Locked Up, Asia’s Mentally Ill Are Left to Inhabit a Living Hell’, , accessed on 22 Jan. 2010. Cahill, Spencer & Eggleston, Robin (1995), ‘Reconsidering the Stigma of Physical Disability’, Sociology Quarterly, vol. 36, no. 4, pp. 681–698. Cao, Xiaobin, Sullivan, Sheena G., Xu, Jie, et al (2006), ‘Understanding HIV-related Stigma and Discrimination in a ‘‘Blameless Population’’’, AIDS Education and Prevention, vol. 18, no. 6, pp. 518–528. Corrigan, Patrick W. & Penn, David L. (1999), ‘Lessons from Social Psychology on Discrediting Psychiatric Stigma’, American Psychologist, vol. 54, no. 9, pp. 765–776. Das, Veena (2001), ‘Stigma, Contagion, Defect: Issues in the Anthropology of Public Health’, paper presented at an international conference on Stigma and Global Health organised by the National Institutes of Health, Maryland, USA, 5 to 7 September 2001. Farmer, Paul (1992), AIDS and Accusation: Haiti and the Geography of Blame, Berkeley, CA: University of California Press. Fogarty International Center (2001), ‘Stigma and global health: developing a research agenda’, paper presented at an international conference on Stigma and Global Health organised by the National Institutes of Health, Maryland, USA, 5 to 7 September 2001.

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Goffman, Erving (1963), Stigma: Notes on the Management of Spoiled Identity, New York: Simon & Schuster. Herek, Gregory M. & Glunt, Eric K. (1988), ‘An Epidemic of Stigma: Public Reactions to AIDS’, American Psychologist, vol. 43, no. 11, pp. 886–891. Jin, Fengqian (2009), ‘People living with HIV/AIDS Must Inform Their Sex Partners in One Month’ (Huan aizi sanshi tian nei xu gaozhi xingduixiang), Western Business in China (Xibu shangbao), 10 November, pp. A-3. Jing, Jun (2006), ‘Social Origins of AIDS Rumors: Moral Panic and Trust Crisis’ (Aizibing yaoyan de shehui yuanyuan: daode konghuang yu xinren weiji), Social Science (Shehui kexue), no. 8, pp. 5–12. Lee, Martha B. & Wu, Zunyou, et al. (2005), ‘HIV-Related Stigma among Market Workers in China’, Health Psychology, vol. 24, no. 4, pp. 435–438. Li, Xiguang & Zhou, Min (eds.) (2005), HIV/AIDS Media Book (Aizibing meiti duben), Beijing: Tsinghua University Press. Link, Bruce G. & Phelan Jo C. (2001), ‘Conceptualizing Stigma’, Annual Review of Sociology, vol. 27, pp. 363–385. Ma, Wenfei & Fan, Zhengxiang (1985), ‘Talking about Super Cancer – AIDS’ (Tantan chaoji aizheng—Aizibing), People’s Daily (Renmin ribao), 31 October, p. 5. Opala Joseph & Boillot Francois (1996), ‘Leprosy among the Limba: Illness and Healing in the Context of World View’, Social Science & Medicine, vol. 42, no. 1, pp. 3–19. Pan, Suiming (2001), ‘AIDS in China - Probability of Sex Transmission’ (Aizibing zai zhongguo - xing chuanbo de kenengxing jiujing you duo da), paper presented at the First National Conference on STD and HIV/ AIDS, 21 to 25 September 2001. Pan, Suiming, Huang, Yingying & Li, Dun (2006), ‘Deconstruction of the “problem” of AIDS in China’, (Zhongguo Aizibing ‘wenti’ Jiexi’), Social Science in China (Zhongguo shehui kexue), no. 1, pp. 85–95.

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Phelan, Jo C., Link, Bruce G., Stueve Ann & Pescosolido, Bernice (2000), ‘Public Conceptions of Mental Illness in 1950 and 1966’, Journal of Health & Social Behavior, vol. 41, June issue, pp. 188–207. Piot, Peter (2000), ‘Report by the Executive Director’, UNAIDS, Rio de Janeiro, 14 December. Qian, H. Z., Wang, N., et al. (2007), ‘Association of Misconceptions about HIV Transmission and Discriminatory Attitudes in Rural China’, AIDS Care, vol. 19, no. 10, pp. 1283 -1287. Qiu, Renzong (2001), ‘A Proposal to the Legislation and Law Reform in Relation to AIDS in the People’s Republic of China’ (manuscript in English). Sontag, Susan (1978), Illness as Metaphor, AIDS and Its Metaphors, New York: Picador. UNAIDS & Partners (2009), The China Stigma Index Report, Beijing: UNAIDS Beijing Office. UNFPA (2006), ‘The Situation of Children and HIV/AIDS in China’, a paper for East Asia and Pacific Regional Consultation on HIV/AIDS and Children, Hanoi, Vietnam, 24 March 2006. Weng, Naiqun (2001), ‘Social and Cultural Construction of AIDS’ (Aizibing de shehui wenhua jiangou), Tsinghua Sociological Review (Qinghua shehuixue pinglun), no. 1, pp. 17–37. Weng, Naiqun (2002), ‘Chinese Ethnic Minorities and Their Encounter with AIDS’ (Zaoyu aizibing de zhongguo shaoshuminzu), a paper presented at Tsinghua-Harvard Symposium on Medical Anthropology, 10 August 2002. Zhang, Hui (2004), Stigma and Discrimination: the Case of HIV/AIDS in China (Wuming Yu qishi – yi zhongguo de aizibing weili), Beijing, MA thesis kept at the Department of Sociology, Tsinghua University. Zhang, Wenkang (1996), ‘Speech at the First National Conference on the Prevention and Control of AIDS in China’ (Zai diyijie quanguo aizibing fangzhi gongzuo huiyi shang de jianghua), Document no. 28, issued by the Department of Disease Prevention and Control, the Ministry of Health, 17 Oct. 1996.

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Zhang, Youchun & Li, Xiaolin (2005), ‘Study of Discriminatory Phenomenon in News Reports on HIV/AIDS’ (Aizibing xuanchuan baodao zhong de qishi xianxiang yanjiu), Chinese Health Education (Zhongguo jiankang jiaoyu), vol. 21, no. 6, pp. 473–475.

Notes 1 This restriction is found, for example, in the health regulations in Chengdu. 2 Many news agencies and newspapers also reported this event.

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9 Ethnicity and Gender in Social Research on HIV in China Huan Jianli

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t the outset, we should note that social research on HIV in China has a short history, mostly because the Chinese community of social scientists until recently regarded the HIV epidemic largely as a medical problem and therefore was slow in recognising the necessity to conduct social research into HIV. Without carrying out research, Chinese social scientists had little to say about HIV. This ‘absence of voice’, as a social anthropologist characterised it (Weng, 2001:17), continued until a Conference on Social Science for HIV/AIDS Prevention and Care in China was held in Beijing in 2001, attended by more than 100 social scientists, public health researchers, health officials and medical practitioners. Organised by Tsinghua University and sponsored by the China-UK Project on HIV/AIDS Prevention and Care, the conference reviewed existing social research on female sex work, male homosexuality, sexual norms and drug abuse. In retrospect, the conference served as a catalyst for social research on HIV in China, because it identified sources of funding and specific topics for research. Less than two years later, the first batch of findings from social research on HIV in China was presented at a conference organised by the Shanghai Academy of Social Sciences. By then, Chinese social science journals were

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beginning to publish a small number of articles on HIV. Over the last decade more and more of these articles have been published.1 In this short space of time, Chinese social scientists have explored a broad spectrum of HIV topics, ranging from behavioural issues and health consequences to the economic impact of HIV, social policy, law and human rights, patient confidentiality, ethnicity and social support of people living with HIV, as well as stigma and discrimination. The basic approach in China’s social research on HIV falls into two categories. The first is a socio-cultural approach that concentrates on values, attitudes, beliefs, behavioural patterns, group dynamics and social psychology. The second is a politicaleconomic approach that highlights inequality, market forces, migration, state policies and institutional bias. While their points of emphasis are rather different, the two categories overlap with one another and are in no way contradictory. This chapter will focus on two major sociological variables central to HIV social research: ethnicity and gender inequality. Social scientists have made a considerable difference to China’s response to HIV by drawing attention through their writings and advocacy to the need to create and integrate a greater degree of social awareness of ethnic differences and gender inequality into HIV prevention, care and treatment.

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Ethnic minorities: Underdevelopment and cultural tradition In an article published in 2000, Yu Xin, a medical researcher at Beijing University, pointed out that the first wave of the HIV epidemic in China, from 1985 to 1995, hit the country’s ethnic minorities hardest. Ethnic minorities made up 36 per cent of the diagnosed cases of HIV, while they constituted only 8 per cent of China’s total population. Yu Xin also pointed out that injecting drug use was the epidemic’s main driving force, responsible for two-thirds of the cumulative tally of confirmed HIV cases reported to the Ministry of Health (Yu, 2000:247– 250). Since the publication of Yu Xin’s article, the number of Han Chinese living with HIV has grown and the percentage of ethnic minorities in the cumulative tally of confirmed cases has  decreased. Ethnic minorities, nonetheless, have remained extremely vulnerable to HIV in Yunnan, Xinjiang, Guangxi and Sichuan. These are four of the six localities in China declared by the Chinese government as ‘high-prevalence regions’. At the end of 2009, the cumulative number of confirmed HIV cases in China came close to 320,000.2 More than 80 per cent of these cases have originated in the six ‘highprevalence regions’. The most active engagement on the vulnerability to HIV of China’s ethnic minorities is by social anthropologists. Taking a political economy approach, Zhang Yuping at Tsinghua

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University addressed the combined issues of HIV and ethnicity from the perspective of cultural survival (Zhang Yuping, 2005a). Coined by the late professor of anthropology David Mabury-Lewis at Harvard University, the notion of cultural survival refers to the ability of distinctive ethnic groups and indigenous people to recall their past while also maintaining control of their destinies in the contemporary and future direction of their cultural traditions.3 Zhang Yuping uses this notion by arguing that the many ethnic groups in China were already faced with a chain of crises in terms of cultural survival before the arrival of the HIV epidemic became evident. Using a selected set of indicators such as household income, absolute poverty, female literacy, reproductive tract infection, alcohol abuse and awareness of health-related risks, Zhang Yuping points out that severe lack of access to education, medical services, new technology and work skills in an increasingly competitive market environment challenges many of China’s ethnic minorities in their attempts to control their own destinies. HIV prevention among these ethnic groups therefore cannot be a simple task of targeting one particular disease; although this disease indeed has the power to further weaken the prospect of cultural survival among those ethnic minorities in their encounter with HIV. She proposes that HIV prevention among ethnic groups must be at least linked with poverty reduction, greater access to education and scaling up of medical services (Zhang Yuping, 2005a: 32–37).

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Similar opinions have been offered by other social anthropologists, especially Cui Yanhu at Xinjiang Normal University, Weng Naiqun at the Chinese Academy of Social Sciences, Ma Linying at the Sichuan Academy of Social Sciences, Du Juan at the Yunnan Academy of Social Sciences, and Hou Yuangao at the Central University of Ethnic Minorities in Beijing (see Cui, 2007; Weng, 2001, 2003; Weng et al., 2004; Ma, 2000; Hou, Munai Reha & Cheng, 2004). But these scholars also have insisted that while attention is paid to the vulnerability of ethnic minorities to HIV, it is imperative to guard against stigmatising characterisations. HIV can serve as another source of discrimination against ethnic minorities in China where the cultural traditions of ethnic minorities are generally negatively perceived by Han Chinese citizens to be backward. In addition, these scholars have pointed out, there is no shortage of public health practitioners and government officials working in the field of HIV prevention who believe that ethnic minorities are more prone to promiscuity and that the border regions of China, where most of the country’s ethnic minority groups live, are fraught with various kinds of dangers, including illicit drugs and uncommon diseases. The fear that social research on HIV may lead to new forms of bias and stigma against ethnic minorities is well founded. A case in point is the research conducted by Zhuang Kongshao at the People’s University of China. His research explored how a group of lineage organisations among the Yi nationality in

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rural Yunnan resorted to religious ceremonies and community watch so as to prevent young men from abusing heroin (Zhuang, 2005, 2007; Zhuang et. al., 2005). He found that rural Yi lineages in general maintained much inf luence over their constituents and that some of these descent-based organisations responded to the arrival of HIV by organising religious ceremonies in which a pledge never to use heroin was taken, together with a pledge of suicide if one used heroin again. These ceremonies were steeped in linguistic and ritual symbolisms typical of the Yi cosmology that emphasises supernatural power, rewards for good behaviour and punishment of evil, and the importance of collectivity over individuality. Because these ceremonies required volunteers among heroin addicts to join and a representative from every household in a given community to attend, they effectively served as a public platform for education in harm reduction and HIV prevention. When first reported at national-level meetings devoted to HIV prevention in China, Zhuang Kongshao’s findings immediately drew fire from some of the leading figures in the Chinese public health sector. Some critics found the use of religion for drug control and HIV education extremely problematic. After all, shamanism, the heart of the Yi religion, is officially defined as ‘superstition’. A documentary film made by Zhuang Kongshao in connection with his ethnographic research contained graphic scenes depicting the sacrifice of

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chickens, pigs and an ox as offerings to mountain gods and local deities. These scenes further convinced his critics that these were superstitious rituals. Other critics felt unnerved by the ritualised pledge of suicide. They argued that HIV prevention and drug control are about saving people’s lives, while the Yi rituals had the potential to destroy human lives. In response, Zhuang Kongshao defended shamanism at meetings and in his articles as a cultural tradition of the Yi. He contended that rejection of ethnic systems of belief and associated religious practices is deleterious to HIV prevention among those ethnic minorities who believe that their cultural traditions can facilitate HIV prevention through communitybased control of illicit narcotics. He also countered the criticism about suicide by explaining that suicide among the Yi is common when one is banished and expelled from a lineage as a result of wrongdoings regarded by the lineage’s constituents as exceedingly shameful. In the Yi cultural tradition, he explained, an exceptionally shameful case of wrongdoing usually leads to the guilty party’s expulsion from the lineage. The worst case of shameful wrongdoing is violation of sexual and religious taboos. In the close-knit kinship system of the Yi people, expulsion brings devastating humiliation to the individuals at fault and their families. Being an established form of punishment in the Yi common laws, the expulsion presents an individual’s social death and his or her family’s disgraced social status. Therefore, a banished individual often chooses

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suicide as a way to demonstrate his or her admission of guilt as well as loyalty to the lineage. Zhuang Kongshao argued that the pledge not to use heroin again is a serious promise when taken at publicly staged ceremonies. Breaking this promise is considered by the locals as a taboo and deeply shameful. So the suicide promise refers to a choice between social death and physical death, he explained. In order to prevent suicides or expulsion from taking place due to the relapse into drug use, these lineages established a system of community watch. The drug users who took the pledges were assigned mentors responsible for mobilising family support for and mutual supervision among those trying to kick their heroin addiction. In Zhuang Kongshao’s view, these efforts to deal with drug abuse and the HIV epidemic cater to the reality of ethnic communities instead of some so-called universal standards of best practice promoted by the public health sector. His film was later aired seven times on television and drew enthusiastic responses from local Yi government officials.

Gender inequality and rural-to-urban migration Social scientists researching HIV-related issues in China work in an environment that requires them to form a close partnership with public health practitioners. This is partly because much of

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the funding for social research on HIV has come from international and government sources allocated to the public health sector and is linked to applied research directly in support of intervention and treatment programs. But Chinese social scientists and public health practitioners, as in other parts of the world, come from rather different professional backgrounds. This difference sometimes makes agreement problematic over questions of priorities, strategies and even categories of target groups in HIV prevention. On the other hand, there have been some successful cooperative ventures as well. One of the successes is the creation of greater gender awareness in China’s HIV prevention. Jin Wei, a social anthropologist by training and now a senior social researcher based in Beijing, is among a group of scholars who have consistently paid special attention to women living with HIV or who are faced with the risks of HIV. For example, she pointed out in a journal article published in 2005 that 19 per cent of China’s cumulative tally of the confirmed HIV cases back in 2000 had been women. The figure had climbed to 28 per cent by 2004. And in the confirmed cases tracked to sexual routes of transmission, 44 per cent were women in 2001; that figure rose to 55 per cent by the middle of 2005 ( Jin Wei, 2005b:3). Her explanation as to why more and more HIV infections involved women is the greater role played by sex in HIV transmission. However, a clearly defined gender-sensitive perspective has been lacking in China’s HIV prevention

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programs. According to Jin Wei, sexually transmitted HIV occurs in the context of gender inequality. Compared with men, the lower awareness of sexual infections, the greater delay in seeking medical treatment, the higher prevalence of illiteracy, and the more likely prospect of being victims of domestic violence tend to work together against women in the age of HIV. ‘And since commercial sex work is illegal in China, female sex workers who cannot turn to the police for assistance when they need to do so are doubly vulnerable to violence and exploitation,’ she noted ( Jin, 2005b:4). Not content with simply identifying the various HIV-related problems faced by women, she proposed a greater integration of China’s HIV response with existing laws regarding women’s rights. In particular, she proposed making HIV testing more sensitive to women’s needs. She also pushed for the domestic development of the female condom and vaginal microbicide whose use could be better initiated and controlled by women. Long Qiuxia, a researcher at the Guangdong Provincial Centre for Women’s Studies, extended the argument about women’s greater vulnerability to HIV even further. In a crosssectional study that she and colleagues conducted in 2003 among 305 respondents in three towns in Guangdong’s Pearl River Delta, she found a common belief among these respondents that condoms were useful only for birth control (Long Qiuxia, 2006; Wang Ying & Long Qiuxia, 2004). In an interesting twist of terminologies, the respondents consistently referred to

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condoms as ‘birth-control sheaths’ in Chinese, instead of ‘safety caps’ as they have been referred to by Chinese health workers specialising in HIV prevention. The belief that condoms are only for birth control was correlated with another finding she made - namely that more than 43 per cent of these respondents had never used a condom in sexual intercourse (Long Qiuxia, 2006: 22). She found that only 13 per cent of the respondents used a condom frequently, while other respondents had an onand-off condom use. Long Qiuxia also discovered an interesting pattern of sexual infidelity: 29.5 per cent of the male respondents reported having had sex with women in addition to their wives or steady girlfriends, while only 10.8 per cent of the women said that they had ever had a sexual relationship with men who were not their husbands or steady boyfriends. All the respondents who reported more than four sexual partners outside a stable sexual relationship were male. In addition, Long Qiuxia found a contradiction in per­ ceptions among the women she interviewed with regard to the place of faithfulness among men in general and among their husbands or boyfriends in specific. ‘They believed that 99 per cent of men are good for nothing and yet their husbands or boyfriends belong to the one per cent of commendable good men,’ (Long Qiuxia, 2006: 23). In her opinion, this notion of male fidelity is a form of false consciousness that increases these women’s vulnerabilities to sexually transmitted infections (STIs) and HIV.

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Women’s possible increased vulnerability to STIs and HIV when they leave rural areas and become migrant workers in cities, and the factors that might make them so, are issues that have been addressed by both social scientists and public health researchers in China. It is important to address these questions because the rural-to-urban labour f low in China since the mid1980s has created a phenomenal population movement – both in terms of Chinese and world history. In the mid-1990s, the number of rural migrant workers in China’s urban areas was estimated to be 53 million. By 2005 that estimate had risen to 100 million, and to 140 million by 2008. Different estimates are offered regarding the gender ratio of these migrant workers. Authorities in Guangdong, for example, believe that women ‘hold up half of the sky’ because the number of females has equalled the number of males among the province’s migrant workers in recent years. The All-China Women’s Federation’s estimate is that women made up 30 per cent of the country’s migrant workers in 2008.4 This estimate still means that more than 40 million rural women, in 2008, migrated to work in urban areas. And as various studies have revealed, female migrant workers tend to be in their 20s and 30s. Of the many social studies on women in China’s rural-tourban migration, a study conducted by Xia Guomei, a sociologist at the Shanghai Academy of Social Sciences, deserves our special attention here since it is directly linked to the impact of rural-to-urban migration and gender inequality on women’s

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vulnerability to HIV. Her study began in 2003 with a random sample survey of more than 5400 respondents in eight rural counties in a southwestern province. These respondents included 3813 rural residents of both genders who had never left their homes for urban jobs and 1620 rural residents of both genders who had worked in urban areas or still had urban jobs when interviewed (Xia Guomei & Yang Xiushi, 2006). Her survey research in the eight rural counties was supplemented by a focused study of 297 rural women working in one of Shanghai’s 19 urban districts in order to bolster her understanding and interpretations of the survey findings. These women were recruited into the study from three massage centres, six hair salons and six karaoke bars. The data indicate that there was a marked difference in selfreported sexual behaviours between both men and women who left their rural homes for urban jobs and those who did not. In a period of three months before their recruitment into her survey study, 13.8 per cent of the respondents in the migrant category engaged in ‘temporary sexual relations’ and 13.9 per cent engaged in ‘commercial sex relations’. In the same threemonth period, 2.8 per cent of the respondents in the nonmigrant category engaged in ‘casual sexual relations’, while 1.8 per cent engaged in ‘commercial sexual relations’. The occurrence of casual sexual relations in the migrant population, as compared with the non-migrant population, turned out to be five times higher. The occurrence of commercial sexual

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relations among the migrant population vis-à-vis the nonmigrant population was nearly eight times higher. In addition, she found that the female migrant workers were more likely than the male migrant workers to engage in casual and commercial sexual relations. The rates of casual and commercial sexual relations among the female migrants were 24.3 per cent and 23.9 per cent respectively, while no more than six per cent of the male migrants had casual or commercial sexual relations (Xia Guomei & Yang Xiushi, 2006: 95–96). Nearly a quarter of the female migrant workers engaged in commercial sex. Xia Guomei’s survey study did not cover condom use, but she focused on this in her study in Shanghai among 297 migrant women. Her Shanghai study found that no more than 15 per cent of these women consistently used condoms in casual sexual relations and commercial sex. To explain her findings in light of HIV prevention, Xia Guomei employed a concept of ‘economic and social exposure’. Economic exposure refers to employment patterns. The statistics she provided indicate that the majority of male migrants work in factories, at construction sites, in self-employed businesses or in clerical positions attached to offices of business entities or government agencies. By contrast, most of the migrant women (63.2 per cent) work in what can be generically termed as the service industry, which includes restaurants, hotels, hair salons, karaoke bars, public bathhouses and convenience stores. And if we add those self-employed women working as nannies, tailors,

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vegetable sellers or operators of small stalls selling f lowers or calling cards, the proportion of migrant women in the service sectors reaches 75 per cent. One fundamental difference between these gendered patterns of employment is women’s overall lack of job security and their lack of protection of basic rights. Xia Guomei informs us that migrant women in general have little bargaining power over the terms of their employment, largely because their jobs are at the socially marginalised and lowest end of urban jobs, and are also least regulated by government agencies. In such an environment, migrant women lack such job-related benefits as paid maternity leave or medical insurance. They can be easily fired without getting any severance pay. To survive in the cities and look for job security and emotional support, they try to build a social network. One way to do this is to form casual sex relations with men. Furthermore, living apart from their families creates ‘social exposure’ to HIV. In their migration from small and close-knit communities where people know one another, they come into a world where most people around them are strangers. In terms of sexual issues they encounter in urban areas, they can afford to ignore the rules that have governed their lives back home. Under the shield of an anonymous existence in urban areas, a significant number of migrant women choose sex work to make a living or as a parttime job. In Xia Guomei’s survey study, nearly a quarter of the migrant women she studied reported that they had provided paid sexual services to men.

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The value of Xia Guomei’s work is that it provides a combination of specific quantitative and qualitative evidence to understand migrant women’s vulnerability to HIV in specific terms. Above all, her research has increased the sophistication of discussions among Chinese social scientists with regard to the impact of gender inequality upon the creation of migrant women’s vulnerability to HIV. And yet, by doing so, her research has become potentially controversial in the Chinese context, because it suggests that a majority of migrant women take on sex work to make money. This may explain why she has downplayed her survey findings and tried to emphasise the economic and social factors that may lead to migrant women’s physical exposure to HIV. In doing so, she has avoided a situation in which her findings could have been used sensationally by the news media.

Sensitivity in Chinese social research on HIV In conclusion, the vulnerabilities of ethnic minorities and migrant women are highly sensitive issues in China’s social research on HIV. Other issues are also highly sensitive for a variety of other reasons. For example, studies on the HIV epidemic in central China by social scientists such as Jing Jun (2006c), Su Chunyan (2009) and Shao Jing (2006) have

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explored the connections of a once-thriving plasma market with an HIV outbreak among rural people who sold their blood as a way to make extra money. These studies are politically sensitive because they may lead to questions of accountability involving state policies in favour of the country’s GDP growth at the expense of public health. Studies on male homosexuality in connection to HIV by social scientists such as Tong Ge (2004), Fu Xiaoxing (2009) and Zhang Yuping (2005b) touch upon a deeply personal orientation of sexuality which suffers from severe stigmatisation in a society where public understanding of homosexuality is extremely superficial and biased. However, the fact that many Chinese gay men marry and have children to please their parents yet continue to have homosexual relations and conceal these relations from their wives raises sensitive questions of responsibility. Studies on female sex work in connection to HIV highlight the tensions that exist between the country’s continued criminalisation of prostitution and the social reality of prostitution as a taken-forgranted profession in existence everywhere in China (Huang Yingying & Pan Suiming, 2003). The many layers of sensitivity in social research on HIV in China require Chinese social scientists to maintain a fine balance between research and politics, between objectivity and advocacy, and between the need to create social awareness through applied research and the need to avoid stigmatising socially marginalised groups. After all, HIV disproportionately

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affects some of the most marginalised groups in Chinese society, who do not want to draw outside attention to themselves. This may explain why few social studies in China have substantially involved representatives of the target groups in research design. More commonly, particularly with studies of sex workers, injecting drug users, and men having sex with men, certain representatives of the target groups are asked to recruit further respondents. But their participation is limited. In retrospect, while social research on HIV has a short history in China, it has generated valuable findings. Some of these have contributed to a greater degree of understanding in the country’s effort to cope with the HIV epidemic. For example, findings from research on female sex workers have been presented to policy hearings, while studies on patient confidentiality have been adopted into teaching cases for journalism training workshops. From time to time, Chinese social scientists appear on Chinese television to address HIV issues. Some have also published their studies in international journals. And more than 30 Chinese social scientists sit on national, provincial and municipal committees for HIV prevention. In this regard, Chinese social scientists have finally gained a voice in an important field of public health.

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References Cui, Yanhu (2007), ‘The Strategies of HIV/AID Prevention and Care in Xinjiang Communities’ (Xinjiang shequ aizibing fangzhi jingyan, wenti yu duice yanjiu), in Working Papers of China-UK HIV/AIDS Prevention and Care Project. Fu, Xiaoxing (2009), Space, Culture and Performance: An Anthropological Ref lection on Male Homosexual Groups in Shenyang (Kongjian, wenhua yu biaoyan: Shenyang nan tongxinglian qunti de renleixue guancha), a doctoral thesis kept at the School of Sociology and Population Studies of the Chinese People’s University. Hou, Yuangao, Munai, Reha & Chen, Guoguang (2004), ‘A Way for Vulnerable Groups to Participate in the STD/AIDS Prevention and Treatment’ (Ruoshi qunti ruhe canyu xingbin aizibing de fangzhi), Journal of the Central University for Nationalities (Zhongyang minzu daxue xuebao), no, 3, pp. 52–57. Huang, Yingying & Pan, Suiming (2003), ‘The Female Sex Workers in the Labor Market Field in Three Cities of Northeast China’ (Zhongguo dongbei diqu laodongli shichang zhong de nüxing xinggongzuozhe), Sociological Studies (Shehuixue yanjiu), no. 3, pp. 51–63. Jin, Wei (2005b), ‘Keeping Women Away from AIDS’ (Rang nüxing yuanli aizi), Social Observation (Shehui guancha), no. 11, pp. 3–5. Jing, Jun (2006), ‘The Titanic Rule: A Risk Analysis of the HIV/AIDS Epidemic in China’ (Taitannike dinglü: zhongguo aizibing fengxian fenxi), Sociological Studies (Shehuixue yanjiu), no. 5, pp. 123–150. Jing, Jun (2006c), ‘A prediction by Titmuss: The Symbiosis of Human Blood Sales and HIV/AIDS’ (Tiemosi yuyan: renxue maimai yu aizibing de luansheng guanxi), Open Times (Kaifang shidai), no. 6, pp. 71–88. Long, Qiuxia (2006), ‘Social and Cultural Reasons for Women’s Susceptibility to AIDS and Coping Measures: Based on an Investigation in Guangdong Province’ (Funü yigan aizibing de shehui wenhua yuanyin tanxi ji duice jianyi), Collection of Women’s Studies (Funü yanjiu luncong), no. 1, pp. 20–25.

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Pan, Suiming, Huang, Yingying & Li, Dun (2006), ‘Deconstruction of the AIDS Problem in China’ (Zhongguo aizibing ‘wenti’ jiexi), Social Sciences in China (Zhongguo shehui kexue), no. 1, pp. 85–95. Shao, Jing (2006), ‘Fluid Labor and Blood Money: The Economy of HIV/AIDS in Rural Central China’, Cultural Anthropology, vol. 21, no. 4, pp. 535–569. Su, Chunyan (2009), A Commodity of Life: Blood Market in Central China (Shengming shangpin: shehuixue shiye xia de zhongyuan xueye shichang), doctoral dissertation kept at the Department of Sociology, Tsinghua University. Tong, Ge (2004), ‘Our Hopes and Expectations’ (Women de xiwang he qidai), The Chinese Journal of Human Sexuality (Zhongguo xingkexue), vol. 13, no. 5, pp. 38–41. Wang, Ying & Long, Qiuxia (2004), ‘Gender Analysis of Factors Related to the HIV/AIDS Epidemic’ (Aizibing liuxing yingxiang yinsu de shehui xingbie fenxi), China Public Health (Zhongguo gonggong weisheng), vol. 20, no. 9, pp. 1073–1074. Weng, Naiqun (2001), ‘The Sociocultural Construction of HIV/AIDS’ (Aizibing de shehui wenhua jiangou), Tsinghua Sociological Review (Qinghua shehuixue pinglun), no. 1, pp. 17–37. Weng, Naiqun (2003), ‘The Sociocultural Motivity of the Prevalence of HIV/AIDS’ (Aizibing chuanbo de shehui wenhua dongli), Sociological Studies (Shehuixue yanjiu), no. 5, pp. 84–94. Weng, Naiqun, Du, Juan, Jin, Liyan & Hou, Hongrui (2004), ‘The Flow of the Heroin, Sex, and Blood and its Products and the Transmission of the Venereal Diseases and AIDS’ (Hailuoyin, xing, xueye jiqi zhiping de liudong yu aizibing, xingbing de chuanbo), Ethno-National Studies (Minzu yanjiu), no. 6, pp. 40–49. Xia, Guomei & Yang, Xiushi (2005), ‘HIV/AIDS related knowledge, attitudes and behaviors among commercial sex workers and their clients’ (Shangyexing Xingjiaoyizhe aizibing renzhi taidu yu xingwei diaocha), Society (Shehui), no. 5, pp. 167–187.

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Xia, Guomei & Yang, Xiushi (2006), ‘Research on Gender, Migration and the Risk of HIV/AIDS’ (Shehui xingbie, renkou liudong yu aizibing fengxian), Social Sciences in China (Zhongguo shehui kexue), no. 6, pp. 88–99. Xu, Xiaojun (2009), ‘Core and Periphery: A Case Study of the Restructuring of Rural AIDS Patients Social Relationships in East Part of Hubei Province’ (Neihe waiwei: chuantong xiangcun shehuiguanxi jiegou de biandong), Sociological Studies (Shehuixue yanjiu), no. 1, pp. 64–95. Zhang, Yuping (2005b), Life as Theatre (Rensheng ru xi), MA thesis kept at the Department of Sociology, Tsinghua University. Zhuang Kongshao (2005), ‘A Probe into Effective Approaches to Civil Drug Control in the Yi Ethnic Region of Little Liangshan’ (Huri de renleixue faxian yu shijian), Study of Ethnics in Guangxi (Guangxi minzu yanjiu), no. 2, pp. 51–65. Zhuang, Kongshao (2007), ‘New Trend in the Prevention and Control of Sexual Diseases and HIV/AIDS in China and the Application of Anthropological Principles’ (Zhongguo xingbing aizibing fangzhi xin taishi he renleixue lilun yuanze zhi yunyong), Journal of Guangxi University for Nationalities (Guangxi minzu daxue xuebao), no. 1, pp. 58–65. Zhuang, Kongshao, Yang, Honglin & Fu, Xiaoxing (2005), ‘Revelation of the Tiger’s Day Initiative in the Yi Ethnic Region of Xiaoliangshan’ (Xiao Liangshan Yizu huri minjian jiedu xingdong he renleixue de yingyong shijian), Journal of Guangxi University for Nationalities (Guangxi minzu xueyuan xuebao), no. 2, pp. 38–47.

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Notes 1 Other social scientists whose research on HIV is noteworthy include Xu Xiaojun ( 2009), Feng Xiaoping & Xia Yuzhen (2008), Zhang Shengkang (2007), Jing Jun ( 2006a; 2006b), Pan Suiming, Huang Yingying & Li Dun (2006), Liu Neng (2005). 2 By the end of October 2009, China’s cumulative tally of confirmed HIV/AIDS stood at 319,877. The country’s estimated HIV/AIDS in 2009 was 740,000. 3 With regard to the concept of cultural survival, one could refer to for more information. 4 These estimated numbers are often cited by government officials and journalists in reference to the urgency to provide social protection to migrant workers.

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Index abominations of the body 178 abortions among sex workers 50–1 academic success see education system accumulation effects 33 age factors among sex workers 32–4, 48, 149 in commencing sexual activity 95 in drug use 67–99 in HIV-positive indiduals 144 AIDS Oral History Project 161–73 AIDS Policy Research Centre 75, 161–2 All-China Women’s Federation 208 anal sex 36–7, 123 Anhui province 20, 103 antenatal clinics, HIV testing compulsory in 142 antibiotic injections 51 antiretroviral treatment for victims of blood trade 16, 182 government policies 130 in Henan 105 shortages 132 anti-stigma campaigns 177 ART see antiretroviral treatment AusAID funding 4 Australian HIV Consortium 4 autonomy in sex work 57 Avian Flu outbreak 114 ‘bathing centres’ 49 bias see discrimination; stigma of AIDS blemishes of individual character 178 blood trade see also plasma trade

commercialisation of 14–6 community support for victims of 167–8 effect on government policy 181–2, 185 HIV spread by 14–21, 101–16 imports banned after contamination found 16–7 oral history of victims 162 private agencies 109–10, 113 re-injection of red cells 112 shame over contracting HIV from 165 targeted by anti-HIV campaigns 34 technological developments in 106–8 testing procedures 111 ‘bodyguards’ of sex workers 58 border regions, cultural bias against 29 businessmen, as sex trade clients 54–5 California gay men study 153 cannabis, grown in China 72 case studies activity after HIV-positive diagnosis 148–52 drug users 80–6 casual sex partners, disclosure of HIV-positive status to 145–6, 154 cell separators 106–7 Central China Television 111 Centre for Disease Control and Prevention 30, 142 centrifuges 18 certification of blood banks 113

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‘chasing the dragon’ drug injections 87 Chengdu city drug-related HIV in 22 gay men in 120–2, 125–7 money boy survey 36 oral history project 162–3 prices for sexual activity 33–4 Chengdu Gay Care Organization 120–2, 125 children of HIV-positive parents bullied at school 178 China Narcotics Control Report 78 China-UK Project for HIV/AIDS Prevention and Care 3, 197 clients of sex trade 53–6, 145–6, 148–9 clustered infections 18–9 coercion-based sex work 58–9 Communist Party see government policies community see also family issues approach to heroin use 201–4 emotional attachment to 127–8 support for HIV-positive individuals 162, 167–8 support for migrant women 211 ‘compulsory detoxification centres’ 73 condoms female equivalent required 206 government promotes use of 62 regarded as evidence of sex work 61–2 seen as for birth control only 206–7 use after diagnosis of HIVpositive status 8, 139–58 use by gay men 36, 124, 129 use by sex workers 33–4, 51, 55 Conference on Social Science for HIV/AIDS Prevention and Care in

China 197 confidentiality breaches attitudes towards 134 for gay men with HIV 7–8, 125–7 in HIV diagnosis 119 contamination of blood donations 111–2 coquettishness 52 corporate sector businessmen as sex trade clients 54–5 discrimination against HIVpositive people by 132–3, 168–9 counselling services 141 criminal code criminalisation of sex trade 61 laws relating to HIV 147, 188–9 critical thinking discouraged 95–6 Cui Yanhu 201 cultural bias among Han Chinese 28–9 Dai ethnic group 27 deaths from AIDS 105–6 depression, increases risk behaviour 153 detention centres for drug users 69–71, 73–5 for sex workers 61 HIV testing mandatory in 142 detoxification programs 69–70, 73, 86 deviant behaviour subculture 94–5 disclosure of HIV-positive status 139–58, 188–90 see also confidentiality breaches discrimination see also stigma of AIDS after media exposure of HIV status 185–6

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against ethnic minorities 201 against gay men 35 against people with HIV 127 against sex workers 59 among Han Chinese 28–9 among medical practitioners 131–4, 184, 187–90 fear of 167 levels of in population 177–8 negative effects on HIV treatment and prevention 190–1 disinfection equipment 112 distress after diagnosis 164 doctors see medical practitioners documented drug users 78 Donghu village, plasma trade in 103 drug trade 67–99 see also heroin use among ethnic minorities 199 estimated number of users 78–9 HIV related to 21–9, 74, 152 HIV testing mandatory for users 142 illicit drugs defined 72 religious rituals to reduce 201–4 targeted by anti-HIV campaigns 34 Du Juan 201 economic and social exposure 210–1 economic development, negative effects of 112–4 education system access to by ethnic minorities 200 education about HIV 183 levels achieved in 144 stratification due to 91–6 elimination process in education 93–4 ELISA testing 111 ‘emic’ approach to HIV 163

emotional problems, drug use and 76 employment discrimination in 132–3 for migrant women 211 medical bill reimbursement and 168–9 sex work based on 57, 59 enemas, use by sex workers 51 ‘entertainment venues’ 54, 62 enzyme-linked immunosorbent activity testing 111 epidemiological survey of Henan 105 epidemiology of HIV in China first HIV case 3, 13 HIV in 11–41 ethnic minorities AIDS among 9 drug use among 23–6 HIV and 144, 195–218 in Chinese society 199–204 ethnographic studies of sex workers 47–8 exposure see confidentiality breaches Factor VIII coagulant 105 faithfulness 207 falang xiaojie 6, 46 false consciousness 207 family issues after diagnosis of HIV-positive status 149–50 approach to heroin use 201–4 for gay men 128–9 for sex workers 51–2, 71 in drug use 85 in HIV narratives 159–73 living with HIV and 8–9 marital status of HIV-positive individuals 144

2 21

HIV IN CHINA

marriage of gay men 122, 124–5 reaction to academic failure 93 reactions to critical experiences 164–9 support for HIV-positive individuals 171 fear after diagnosis 164, 180 female sex workers 43–65 see also sex trade fidelity 207 fines for sex work 61 first HIV case in China 13 first stage of reaction to diagnosis 164, 169 Fong, Vanessa 93 ‘Four Free and One Care’ policy 129–30 friends see community; peer group issues Fu Xiaoxing 213 Fuyang city 103, 113 Gansu province 188–90 Gao Yaojie 18, 104 gay men criminalisation of 122–3 disclosure decisions by 153, 170 fears of exposure 117–37, 167 HIV among 5, 7–8, 34–7 oral history project 162 studies of 213 GDP mentality 113 Geiju city 86, 119 gender issues 195–218 ‘girl talks’ among sex workers 55 Global Fund to Fight AIDS, Tuberculosis and Malaria 20 Goffman, Erving 178 Golden Crescent drug use 23 government policies see also Ministry of Health; Ministry of Justice; Ministry of Public Security

after SARS crisis 114 early view of HIV 181–2 effect on drug trade 72 effect on sex trade 45, 60–3 ‘Four Free and One Care’ policy 129–30 HIV surveillance 121 laws and regulations relating to HIV 188–9 laws to protect people with HIV 127 on promoting safe sex 62 under new leadership 13 Guangdong province drug-related HIV in 22 estimated number of sex workers 30–2 migrants into from rural areas 208 women’s attitudes to condoms in 206–7 Guangxi province 22, 199 Guizhou city 22 haemophiliacs, infection of with HIV 105 hair-salon girls 6, 46 Han Chinese as proportion of HIV-positive indiduals 144, 199 cultural bias among 28–9 Handbook of Plasmapheresis 108–9 ‘handlers’ of sex workers 53, 57 He Mingjie xi, 8–9, 189 healthcare providers see medical practitioners; Ministry of Health Hebei province 20 Henan province blood trade in 16–7, 19, 110 HIV tests not available in 20 plasma trade and AIDS epidemic 103–4

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hepatitis B 114 hepatitis C 105 heroin use 6 see also drug trade among sex workers 70–1 as drug of choice 72, 77 detoxification programs 69–70 estimates of 90 HIV related to 21–2 religious rituals to reduce 201–4 heterosexual sex becomes main driver of AIDS epidemic 30 ‘high-risk group’, term for 187 HIV as ‘decadent’ disease 181–3 blood donors screened for 114 care and treatment of people with 129–33 condom use after diagnosis of 139–58 crimes relating to 147, 189 disclosure reduces transmission risks 153 drug use and 67–99 family issues and 159–73 first case of 3 government surveillance of 121 in China 11–41 incidence among gay men 121–2 inside detention centres 74 poor knowledge of 36 sensitivity of research into 212–4 sexual transmission of 205 social research capacity 1–10 stigma of AIDS and 175–94 testing procedures 111 home towns, treatment only available in 130–1 homosexual men see gay men Hou Yuangao 25, 201 household registration 50, 130–1 housing-based sex work 58–9 Houyang village 106

Hu Jingtao 114 Huan Jianli xi, 9–10 Huang Yingying ix, 6 identity deception, in blood trade 111 illicit drugs see drug trade; heroin use illiteracy in women 206 incarceration see detention centres injected drug use 79 see also heroin use ‘innocent victims’ 181, 185 instant gratification 95 internalised stigma 180 Internet, sex work via 45 ‘iron-cast brothers’ 55 Jin Wei 205–6 Jing Jun ix, 5–6, 105–6, 162, 212 Jingpo ethnic group 28 KABP tool 180 Kaiyuan city 142–4, 149 kinship systems see family issues Kippax, Susan 4–5 Kunming city 22, 69–70 labelling 179 labour camps see detention centres Lao Ji 185–6 Leshan city 86 Li Yinghe 123 Li Zongtao 75 Liangshan prefecture 22–3, 26 Liao Longhui 80 lineage organisations 201–4 Liu Dalin 124 Liu Hongjie 36–7 Liu Junxiang 107–8 Liu Zhimin 80 Long Qiuxia 206–7

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long-term partnerships see marriage and partnership Ma Linying 25–6, 201 Ma Yongqing 75–6 Mabury-Lewis, David 200 malaria outbreaks 105 male homosexuals see gay men ‘managers’ of sex workers 53, 57 map of China xii marriage and partnership see also family issues among HIV-positive individuals 144, 154 disclosure of HIV status in 145–6 effect of HIV-positive status on 133–4 faithfulness in 207 gay men in 122, 124–5 massage parlours 58 MB see ‘money boys’ media attitudes to HIV 166, 182–6, 214 medical care and treatment costs of 168–9 family involvement in 171 HIV testing before compulsory 142 medical insurance 126, 168–9 medical practitioners bias and discrimination among 131–4, 184, 187–90 social scientists work with 204–5 men who have sex with men see gay men methadone programs 73–4 methamphetamine use 77–8 migrants from rural to urban areas drug use among 91 gender issues and 204–12 involvement in sex trade 32, 49 treatment only available in home

towns 130–1 women a high proportion of 208–9 military hospitals, blood collection by 113 Ministry of Health develops domestic blood trade 17 promotes plasma trade 108 survey of HIV among gay men 122 Ministry of Justice, detention centres run by 73 Ministry of Public Security see also police detention centres run by 73 estimates of number of sex workers 30 policy on condom possession and use 61–2 misconceptions about HIV 180 missionary hospitals 14 ‘money boys’ 35–7 moralisation 180–1, 188 ‘most-at-risk populations’ 163 MSM see gay men Myanmar, methamphetamine made in 78 Nandawu village 106 Nanjing city, money boy survey in 36 narcotics see drug trade; heroin use National Committee for HIV/AIDS Prevention and Treatment 62, 143 National Narcotics Control Commission 78, 90 National People’s Congress 15 needles, re-use of 112 New York Times 104 news media see media attitudes to HIV non-documented drug users 78

2 24

index

nurses see medical practitioners old age support by families 171 opium, trade in banned 72 oral sex, attitudes to 52, 123 Pan Suiming 31–2, 123 parental reactions see family issues partnership see marriage and partnership Pearl River Delta region 31, 206–7 see also Guangdong province peer group issues academic failure and 94–5 for sex workers 51–2 in starting drug use 75–7 People’s Daily 183–4 personal relationships 145 see also family issues; marriage and partnership; peer group issues personal safety issues in sex trade 46–7, 49–50, 53 learning safe practices 55 women disadvantaged by 206 philosophy of life 95 physical abuse see personal safety issues physical problems, drug use and 76 pimps 53, 57 plasma trade 15–6 see also blood trade centrifuges in 18, 107 HIV and 20, 213 importation banned 17 study of 103–4 targeted by anti-HIV campaigns 34 plasmapheresis 7, 108–9, 114 police see also Ministry of Public Security harassment of sex workers 50, 61–2

HIV-positive officer in 119 political–economic approach to HIV 185–6, 198 poverty see also socioeconomic issues as driver of HIV epidemic 25–6 due to urban unemployment 91–2 in ethnic minorities 200 sex work in response to 33, 59 power exercise in discrimination 180 pregnancy among sex workers 47, 50–1 prejudice see discrimination; stigma of AIDS private blood collection agencies 109–10, 113 Project for Drug Rehabilitation via Methadone Treatment 70 prostitution see sex trade psycho-social distancing 145–6, 148, 153–4 reasons for drug use 76 red cells, injection back into donors 18 registration for treatment 50, 130–1 regulations see criminal code; government policies Regulations for HIV/AIDS Prevention and Control 147 rehabilitation centres for drug users 69–71 relapse rate for former drug users 70, 77, 86–92 religious rituals, approach to heroin use 201–4 residency registration cards 50, 130–1 revenge as motivation for transmitting HIV 151

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risk behaviours see heroin use; personal safety issues; unsafe sex rural populations see also migrants from rural to urban areas attitudes to blood sales 109–10 blood trade and AIDS in 7, 19–20 community support for heroin users 204 community support for victims of blood trade 167–8 migration of to urban areas 31 safe sex see unsafe sex safety issues see personal safety issues; unsafe procedures SARS crisis 13, 114 school system see education system scientism 183 second stage of reaction to diagnosis 164, 169 self-employment in sex trade 210–1 separation 179 service industries, migrant women in 210–1 Severe Acute Respiratory Syndrome crisis 13, 114 sex trade HIV and 29–34, 152 occupational concerns 43–65 practices in 53–60 prices in 33–4, 49 prohibition of 45, 60–1 reality of and laws against 213 tourism related to 27 sex workers classification of 32–4, 45 clients disclose their HIV-status to 145–6, 148–50 drug use among 70–1, 89–90 estimated number of 30, 45 from rural areas 209–12

health promotion among 6 in detention centres 74 knowledge held by 53–60 male, rarity of 123 targeted by anti-HIV campaigns 34 vulnerability to exploitation 206 sexual activity see also sex trade; unsafe sex age of commencement 95 among ethnic minorities 201 changing attitudes towards 184–5 gender differences in levels of 207 heterosexual sex 30 HIV transmission by 205 migrants from rural areas 209–10 money boys 36–7 sex workers’ role in 48–9, 54 support networks built via 211 tourism related to 27 sexually transmitted infections among hair-salon girls 46 among money boys 36 among sex workers 50–1 HIV classed with 181 prevention of 6 shamanism 202–3 shame over contracting HIV 165–7 Shangcai prefecture 106 Shanghai Academy of Social Sciences 197 Shanghai city 209–10 Shao Jing 212 Shenyang city 36 Shilipu village 106 shock of diagnosis 165 sibling reactions see family issues Sichuan province drug use in 75 drug-related HIV in 22

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ethnic minorities in 28, 199 HIV epidemic in 24–5 social anthropological approach 199–200 social development, priority of 112–4 social emulation 110 social geography cultural bias against border regions 29 drug use and 26 in blood trade 19–20 social research capacity 1–10 social risks, in blood trade 108–12 social scientists approach to HIV research 180–1, 197–8 work with medical practitioners 204–5 social support see community; family issues socio-cultural approach to HIV 179, 198 socioeconomic issues see also poverty economic and social exposure 210–1 ethnic minorities and 200 HIV and 5, 26 in drug use 76–7, 85 in effects of AIDS 14 marginalisation of young people 90 sex work provides freedom 52 stratification due to education 91–6 sodomy charges 122 solicitation in sex trade 53 Sontag, Susan 187 State Council AIDS Working Committee Office 20 State Regulation of HIV/AIDS Prevention and Treatment 62

status loss 179 stereotyping 179 stigma of AIDS 9, 175–94, 201 see also discrimination STIs see sexually transmitted infections structural stigma 180, 183 Su Chunyan x, 6–7, 162, 212 suicide, as a reaction to shame 203 Sun Yongli x, 8, 189 supervision of ex-drug users 86–7 Swine Flu outbreak 114 synthetic drugs 72, 77–8 technical risks, in blood trade 108–12 technological developments in blood trade 106–8 third stage of reaction to diagnosis 165, 169–70 Tong Ge 213 tourism in Yunnan province 27 training for social scientists 10 tribal stigma 178 triple-companion misses 31 Tsinghua University 3–4, 197 UN Theme Group on AIDS in China 20 UNAIDS 45 underdevelopment of cultural minorities 199–204 unemployment, links with drug use 90–2 United Kingdom, joint program for HIV prevention 61 United States, contaminated blood products from 16–7 universities, ranking of 94 University of New South Wales 3 university students, numbers of 92–3

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female sex workers 43–65 with HIV 205–6 Worth, Heather ix, 5 Wu Zongjian 123

unregistered blood collection businesses 17 unsafe procedures, in blood trade 17, 108–12 unsafe sex 22 see also condoms after diagnosis of HIV-positive status 147–52 among sex workers 33 clients’ pressure for 55 counselling focusses on 141 gay men’s knowledge about 123–4 reasons for 154–5 urban populations 49, 90–2 see also migrants from rural to urban areas Urumqi city, drug use in 80 Uyghur ethnic group, HIV prevalence among 23, 28

Xia Guomei 32, 208–12 Xiao Li 50–1 Xiao Wei 185–6 Xincai prefecture 103 Xinjiang province ethnic minorities in 199 HIV epidemic in 24–5 HIV incidence 23 illicit drug use in 21–2 Uyghur ethnic group in 23, 28

vaginal microbiocides 206 VCT see counselling services venereal infections see sexually transmitted infections villages see community; rural populations violence, risk of see personal safety issues voluntary counselling and testing see counselling services voluntary detoxification programs 73

Yi ethnic group approach to heroin use 201–4 drug-related HIV among 22–3, 25 HIV prevalence among 28 involvement in drug trade 26–7 Yu Jing 162 Yu Xin 23–4, 199 Yunnan province condoms provided in hotels 62 confidentiality breaches in 119 drug use in 21–2, 75–6, 81 ethnic minorities in 27–8, 199 HIV epidemic in 24–5

Wang Jun 80 Wang Xiaobo 123 war metaphors 187 Wen Jiabao 114 Weng Naiqun 201 Wenlou village 106 Western Blot testing 111 ‘Western’ disease, HIV as 183–4 women see also gender issues AIDS among 9

Zhang Beichuan 124 Zhang Hui 162 Zhang Ke 18, 103–4 Zhang Ying 103 Zhang Youchun xi, 9 Zhang Yuping x, 7–8, 162, 199–200 Zhu Lin 81 Zhuang Kongshao 201–4 Zhumadian city 16–7

228