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Print version ISSN 0042-9686
Bull World Health Organ vol.87 n.11 Genebra Nov. 2009
One stone to kill two birds
China's economic boom has triggered mass migration of rural workers to cities in search of higher incomes and better opportunities. This trend over the past two decades is a major factor in the resurgence of STIs in China. Reporter Cui Weiyuan talks to Professor Xiang-Sheng Chen about how detection and care of STIs can and should be linked to that of HIV.
Q: Why is China experiencing a re-emergence of syphilis?
A: China had 278 215 officially reported syphilis cases in 2008, tripling the number of cases reported in 2004. This is a tenfold increase over the past decade, according to statistics from China's STI surveillance system. On average, syphilis cases are increasing by 30% a year across the nation. China virtually eradicated syphilis in the 1960s through a powerful campaign of propaganda, mass screening, closing brothels and providing free treatment for sex workers. But the epidemic has re-emerged since the economic boom of the 1980s. We don't know whether the first case of syphilis in 1979 was imported or not, but we know that the resurgence of syphilis was driven by prostitution, migration of workers and poor health controls. Migrant workers, mainly young men who have left their wives back in their home towns, make up much of the clientele of low-tier sex workers. These sex workers frequently provide services and are less aware of the risks of STIs, such as syphilis and HIV, compared with their higher-tier counterparts working in star-rated hotels. It is difficult to promote condom use among these individuals, as they are poorly educated and some cannot even afford a condom. Men who have sex with men are also a high-risk group. A national survey in 2008 found that 11.9% of this group were infected with syphilis, while 4.9% were HIV positive. [These data were presented in the National Conference of HIV and STI in 2009 by the Chinese health authorities.] The areas with higher syphilis prevalence are usually places where the economy is booming but where there is also greater economic inequality, such as the south-eastern coastal areas.
Q: What are the challenges working in this field?
A: When visiting entertainment parlours to screen female sex workers for syphilis, my staff and I often receive wariness, mistrust, hostility and even verbal or physical harassment from their "bodyguards". In China, the outreach team consists of people mainly from the local CDC, and sometimes also from the local hospitals. We have to be patient, friendly and show them respect. Once we gain their trust, we find that many female sex workers are not only interested in learning about HIV or syphilis, but they often ask questions about maternal health, abortion and so on. We then added a reproductive health consulting service to the HIV/STI education during our regular visits. Many female sex workers would not hesitate to visit a specialized doctor, but say they can't afford it because they serve very poor clients and are no better off themselves. In this case, we need to provide a summary of the real costs and benefits of seeking care, an analysis most sex workers have not considered. We need to put ourselves in their shoes. It takes time and lots of effort to build up trust. But we manage it in the end.
Q: How is China dealing with people's unwillingness to visit STI clinics?
A: People who visit these departments in public hospitals often face social stigma. Their privacy and confidentiality are not very well protected. Also, the high cost of testing and treatment and limited opening hours make these services less accessible. In recent years China has introduced reforms. For instance, most public hospitals have put their STI departments under the dermatology department. In general hospitals in cities, maternal or women's health units provide limited HIV and other STI testing services. Many clinics have a separate space for checking and screening to protect outpatients' privacy and make the process more humane. A system of keeping records confidential is also being established. Despite these efforts, more than half of China's STI patients do not visit these places. We have tried hard to encourage sex workers and clients at entertainment parlours to go to the clinics for testing, but many do not believe they might be infected. Currently, my institute - in collaboration with WHO - is offering point-of-care syphilis testing, providing results in 15 to 20 minutes. It enables testing at non-traditional venues, avoiding the stigma attached to visiting STI clinics. If a person needs treatment, our staff can make prompt referrals. Our study showed us that prevention and screening is needed not only at the "barbers' shops" (brothels), massage parlours and karaoke bars. We discovered that many of the high-risk low-tier sex workers serve clients on the street, in rented rooms or in dilapidated houses on the urban fringes. We need to provide comprehensive prevention and screening to these neighbourhoods where migrant workers and the urban poor live. In addition, we are piloting a project to see whether provision of such syphilis testing can be used as an entry point to encourage the clients for HIV testing.
Q: Are HIV and STI services integrated in China?
A: The link between HIV care and detection services for other STIs in China is weak. Syphilis testing is included in some HIV voluntary counselling and testing programmes, but that is the extent of the connection in many places. No other STIs are included. Some maternal and child health-care centres are planning to integrate syphilis into their treatment packages, but lack the funding to do so. Syphilis screening and detection services are integrated into some HIV prevention and control programmes, mainly implemented by the China CDC's programmes for high-risk groups. But this only helps us to understand the spread of the disease, since little care for syphilis is provided following the testing.
Q: Do many people in China have both HIV and other STIs?
A: There are no national statistics on this because the HIV reporting system and that of other STIs are separate. But it appears that HIV combined with other STIs, especially syphilis, is on the rise in high-risk groups. One reason is that HIV and other STIs can be sexually transmitted, while HIV and other STIs encourage each other's spread. For example, someone with HIV and an ulcerative STI - such as syphilis, genital herpes or chancroid - can transmit HIV more easily. It is also more difficult to treat the STIs contracted by people infected with HIV. Indeed, this combination can accelerate the spread of both HIV and other STIs, and worsens both epidemics. Moreover, in some areas many female sex workers are also drug users and are at high risk of contracting HIV and other STIs. We need to reinforce the control of other STIs, which are mostly curable, to help prevent and detect HIV.
Q: What programmes are in place to raise awareness of HIV and STI prevention?
A: A public awareness campaign has been conducted across China to educate people about safe sex and HIV/AIDS, particularly over the past decade. This involved public interest television spots, theatrical performances, posters in public places and school education in safe sex, etc. Education programmes that focus on high-risk groups are also a major part of national HIV prevention campaigns. There are prevention programmes that reach out to migrant workers, in the workplace and at the entertainment parlours where they are the patrons. Also, promotion of condom use among high-risk groups allows us to kill two birds with one stone, with regard to preventing sexually transmitted HIV and other STIs.
Q: What are the challenges in effective prevention, care and treatment for STIs and/or HIV?
A: There are many challenges. First, these epidemics are on the rise in China, but the policies for STI prevention, care and treatment are still being developed. Second, although the central government has called for cooperation between relevant departments, conflicts of interest between departments, such as those responsible for public health and public security, may think differently about the services needed to reach drug users and sex workers. Third, the public health system is divided on how best to tackle disease control and prevention. From the disease control perspective, we believe that detection and treatment of STIs should be decentralized, but hospital administrations push for resources for STIs to be centralized and concentrated in their hospitals. Public awareness campaigns about STIs are not given as high a priority as they should. Unlike many Western countries, China does not have an STI public health programme - which it should have. Fourth, state policy has focused mainly on HIV/AIDS. Little attention has been paid to other STIs and their STI testing and treatment are regarded by health service providers as a source of profits. It is essential to have public policies that prioritize prevention, intervention and treatment of STIs to improve the cooperation between different departments and within the public health system, and to allocate resources for STI issues, rather than commercializing these services.