Human Immunodeficiency Virus Prevention Strategies in China

The human immunodeficiency virus (HIV) epidemic in China has undergone significant transformations over the past three decades, with prevention strategies evolving in response to shifting transmission patterns and scientific advancements. Initially driven by transmission through blood and injection drug use, the epidemic is now dominated by sexual transmission, which accounts for 95% of newly diagnosed HIV infections as of 2018. Despite progress in reducing transmission via blood and injection drug use, the annual number of newly diagnosed HIV cases continues to rise, exceeding 148,500 in 2018. This underscores the urgency of implementing and refining prevention strategies tailored to China’s unique epidemiological landscape.

General Prevention Measures

Educational Campaigns
Education remains a cornerstone of HIV prevention. Over the past three decades, public awareness of HIV/AIDS in China has improved significantly. A pivotal moment was the 2004–2005 national HIV testing campaign targeting former plasma donors, which mobilized governmental and international organizations to disseminate knowledge about HIV transmission and reduce stigma. Despite these efforts, educational initiatives often fail to address the specific needs of vulnerable populations, such as rural communities and migrant workers. Studies highlight that factory workers, rural residents, and students exhibit lower HIV awareness, necessitating targeted face-to-face interventions in these settings. Educational campaigns must transition from generic messaging to culturally sensitive, audience-specific strategies to optimize impact.

HIV Testing and Counseling
Voluntary counseling and testing (VCT) and provider-initiated testing and counseling (PITC) are critical for early diagnosis and linkage to care. By 2018, China had established over 10,000 VCT sites, diagnosing 27% of new HIV cases that year. However, hospital-based diagnoses still dominate, with approximately 60% of HIV tests and over 50% of diagnoses occurring in clinical settings. Early diagnosis through VCT is associated with timely antiretroviral therapy (ART) initiation, which improves individual outcomes and reduces community transmission. Despite progress, late diagnoses persist, highlighting the need for expanded testing in non-clinical environments and increased public willingness to seek testing.

Specific Prevention Measures

Safe Blood Supply
China has made remarkable strides in ensuring blood safety since the mid-1990s plasma donor crisis. The introduction of HIV RNA testing in 2015 reduced the diagnostic window period to 10–14 days, minimizing transfusion-related HIV risks. However, challenges remain, particularly regarding blood donations from high-risk populations like men who have sex with men (MSM), who often use blood donation as an indirect means of HIV testing. Enhanced donor screening, behavioral risk assessments, and stricter oversight of blood collection processes are essential to eliminate residual risks.

Harm Reduction for People Who Inject Drugs
China’s harm reduction programs, including methadone maintenance therapy (MMT) and needle-syringe exchange programs, have drastically reduced HIV incidence among people who inject drugs (PWID). From 2006 to 2018, HIV incidence in MMT clients plummeted from 1% to 0.03%, and transmission via injection drug use dropped from 44.2% (2005) to under 3% (2018). These successes underscore the importance of sustaining harm reduction initiatives to prevent resurgence, as seen in other countries experiencing opioid-driven HIV outbreaks.

Condom Promotion
Condom use remains a key strategy for reducing sexual HIV transmission. Sentinel surveillance data from 2015 indicated 77% condom use among female sex workers and 53% among MSM during their last sexual encounter. Despite these figures, HIV prevalence among MSM surged from 1% (2006) to 8% (2015), illustrating the limitations of condom-only approaches. Sustained condom promotion must be integrated with other interventions, such as pre-exposure prophylaxis (PrEP) and ART, to curb transmission among high-risk groups.

Treatment of Sexually Transmitted Infections (STIs)
STIs increase HIV susceptibility by compromising mucosal barriers. Although STI treatment can reduce HIV transmission in high-prevalence settings, China lacks a cohesive national STI management strategy. Strengthening STI care services, reducing stigma, and integrating STI screening with HIV programs are vital for synergistic prevention.

Prevention of Mother-to-Child Transmission (PMTCT)
China’s PMTCT program, integrated with syphilis and hepatitis B prevention, has achieved notable success. By 2017, over 99% of HIV-positive pregnant women received testing, and 90% accessed ART, reducing mother-to-child transmission from 12.8% (2005) to 4.9% (2017). Challenges include ensuring consistent ART adherence and improving rural healthcare access to eliminate vertical transmission entirely.

Newly Developed Prevention Measures

Treatment as Prevention
The landmark HPTN 052 trial demonstrated that ART reduces HIV transmission by 96% in serodiscordant couples. In China, treatment-as-prevention policies for such couples lowered transmission rates from 2.6% (2011) to 0.68% (2017). Success hinges on early ART initiation, viral load monitoring, and adherence support. Programs must prioritize rapid linkage to care and community-based adherence interventions.

90-90-90 Strategy
Aligned with global targets, China aims to diagnose 90% of HIV cases, treat 90% of diagnosed individuals, and achieve viral suppression in 90% of those treated. A 2015 survey revealed 68% diagnosis, 67% treatment, and 65% suppression rates, indicating gaps in testing accessibility and retention in care. Accelerating progress requires decentralized testing, stigma reduction, and task-shifting to community health workers.

New Social Media
Social media platforms like Blued, a popular app among MSM, have emerged as innovative tools for HIV education and testing promotion. Blued’s integration of prevention messaging and testing reminders exemplifies how technology can engage high-risk populations. Expanding such initiatives requires collaboration between public health agencies and tech companies.

Detection and Treatment of Acute Infection
Acute HIV infection, characterized by high viral loads, contributes disproportionately to transmission. Despite its epidemiological significance, China lacks guidelines for acute infection management. Pilot studies suggest that early diagnosis and treatment could reduce transmission by up to 88%, but operational challenges, such as identifying acute cases and ensuring rapid ART initiation, must be addressed.

Pre-Exposure and Post-Exposure Prophylaxis
PrEP, using tenofovir/emtricitabine, reduces HIV acquisition risk by up to 90% when adhered to consistently. However, PrEP uptake in China remains low due to cost, accessibility, and awareness barriers. Conversely, post-exposure prophylaxis (PEP) is well-established for occupational exposures, with no reported HIV transmissions among healthcare workers adhering to PEP protocols. Expanding PrEP/PEP access, particularly for MSM and serodiscordant couples, requires policy support, subsidized pricing, and provider training.

Male Circumcision
Voluntary medical male circumcision (VMMC), proven to reduce heterosexual HIV transmission by 60% in Africa, has limited applicability in China. Pilot studies among MSM showed low acceptability, and with HIV prevalence at 0.08% nationally, VMMC is not a prioritized strategy.

Future Prevention Strategies

Microbicides
Topical microbicides, such as dapivirine vaginal rings, offer discreet HIV prevention for women. Trials show modest efficacy (31%), but long-acting formulations could enhance adherence. China’s research on microbicides, though nascent, holds promise for reducing sexual transmission, particularly among women lacking negotiation power for condom use.

Vaccines
Despite decades of research, no effective HIV vaccine exists. The RV 144 trial in Thailand demonstrated 31% efficacy, but vaccine development remains challenged by viral mutation and immune evasion. While a vaccine is unlikely in the near term, continued investment in research is critical for long-term epidemic control.

Conclusion

Controlling HIV in China demands a multifaceted approach combining education, biomedical interventions, and structural reforms. Sexual transmission, now the dominant mode, requires intensified focus on high-risk groups like MSM, female sex workers, and youth. Strategies must prioritize early diagnosis, universal ART access, and innovative prevention tools like PrEP. Sustained political commitment, community engagement, and integration of services across healthcare systems are essential to reverse the rising tide of HIV infections.

doi.org/10.1097/CM9.0000000000000647

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