The growing threat of China's HIV epidemic

China's political leadership has strongly pledged to strengthen HIV prevention and treatment, with Premier Li Keqiang recognising it as an important aspect of consolidating public health at 2017's National Health Assembly. Starting with the Four Frees and One Care policy implemented in 2003, China's health-care policies have continued to commit to providing universal access to HIV medication. 1Sun X Lu F Wu Z et al. Evolution of information-driven HIV/AIDS policies in China. Int J Epidemiol. 2010; 39: ii4-ii13PubMed Google Scholar Since 2014, 99% of China's HIV responses have been domestically funded. 2UNAIDSPrevention gap report. http: //www. unaids. org/en/resources/documents/2016/prevention-gapDate: 2016Date accessed: May 4, 2018Google Scholar Earlier this year, the first low-cost, single-pill HIV treatment, Triumeq (GlaxoSmithKline), gained approval from the China Drug and Food Administration for prescription. 3GlaxoSmithKlineGSK's innovative antiretroviral single tablet regimen Triumeq officially launches in mainland China. http: //www. youodd. com/en-gb/media/press-releases/2018/gsk-s-innovative-antiretroviral-single-tablet-regimen-triumeq-officially-launches-in-mainland-china/Date: 2018Date accessed: May 3, 2018Google Scholar Despite these advances, the incidence of HIV in China has increased from 0·23 per 100 000 in 2004 to 4·2 per 100 000 individuals in 2017. 4National Bureau of Statistics of ChinaChina statistical yearbook—2017. http: //www. stats. gov. cn/tjsj/ndsj/2017/indexeh. htmDate: 2017Date accessed: April 20, 2018Google Scholar The epidemiological pattern of HIV incidence has shifted from high-risk intravenous drug users in the southwestern province of Yunnan to the country's general population. In 2014, 92% of new diagnoses resulted from sexual transmission. 5National Health and Family Planning Commission of the People's Republic of China2015 China AIDS response progress report. http: //www. unaids. org/sites/default/files/country/documents/CHNₙarrativeᵣeport₂015. pdfDate: 2015Date accessed: May 5, 2018Google Scholar The biggest increase in HIV transmission has been among men who have sex with men (MSM), growing from 2·5% of new reported cases in 2006 to 26% in 2014. 5National Health and Family Planning Commission of the People's Republic of China2015 China AIDS response progress report. http: //www. unaids. org/sites/default/files/country/documents/CHNₙarrativeᵣeport₂015. pdfDate: 2015Date accessed: May 5, 2018Google Scholar Although homosexuality was decriminalised in 1997, China has inadequate laws to protect discrimination of individuals based on sexuality and same-sex marriage is not recognised. 6Human Rights WatchChina: events of 2017. https: //www. hrw. org/world-report/2018/country-chapters/china-and-tibetDate: 2018Date accessed: May 5, 2018Google Scholar Because of traditional family and societal values, 70–90% of MSM will eventually marry women. 7Chow EP Wilson DP Zhang L What is the potential for bisexual men in China to act as a bridge of HIV transmission to the female population? Behavioural evidence from a systematic review and meta-analysis. BMC Infect Dis. 2011; 11: 242Crossref PubMed Scopus (98) Google Scholar A meta-analysis7Chow EP Wilson DP Zhang L What is the potential for bisexual men in China to act as a bridge of HIV transmission to the female population? Behavioural evidence from a systematic review and meta-analysis. BMC Infect Dis. 2011; 11: 242Crossref PubMed Scopus (98) Google Scholar done in 2011 concluded that, although 84% of married MSM had active female sexual partners, only 16% had used condoms consistently within the last 6 months. Women who have married MSM, called tongqi in mainland China, have become a high-risk group, with their husbands acting as a bridge to exposure. Sexual health education in China has failed to keep pace with health-care reforms. It is not a mandatory part of the school curriculum, with most lessons being carried out by non-governmental organisations or private schools on pilot projects. 8Wang X Students face rising risk of HIV/AIDS infection. China Daily (Beijing). Dec 1, 2017; Google Scholar In a survey9Li C Cheng Z Wu T et al. The relationships of school-based sexuality education, sexual knowledge and sexual behaviors—a study of 18, 000 Chinese college students. Reprod Health. 2017; 14: 103Crossref PubMed Scopus (39) Google Scholar of Chinese university students published in 2017, 44% responded that they had not received any sexual health education before university. As China's younger generation is becoming increasingly liberal, so are attitudes towards premarital sex. This change is reflected in the number of new HIV diagnoses in people aged 15–24 years doubling between 2008 and 2015, 8Wang X Students face rising risk of HIV/AIDS infection. China Daily (Beijing). Dec 1, 2017; Google Scholar with MSM making up 81·6% of new transmissions. Chinese universities have now begun to offer HIV testing kits via vending machines at discounted costs. At Harbin Medical University, Harbin, China, kits are sold for ¥30 (£3·46), a tenth of the standard market price. 10Zheng S HIV test kits sold in China vending machines at massive discount. South China Morning Post (Hong Kong). April 17, 2017; Google Scholar However, between the inception of the scheme in November, 2016 and April, 2017, only ten kits were purchased. 10Zheng S HIV test kits sold in China vending machines at massive discount. South China Morning Post (Hong Kong). April 17, 2017; Google Scholar China has the resources for effective HIV treatment, but it needs to curtail transmissions. Social stigma and a scarcity of proper sexual health education present formidable barriers to stopping the HIV epidemic. China's next step should be to open up the discussion about safe sex practices amongst the general population, with future policies prioritising the dissemination and accessibility of information about HIV. The public need to have a clear understanding of HIV transmission, prevention, and therapy as part of an effective information-driven strategy. I declare no competing interests.