CHINA FINALLY TAKING STEPS TO FIGHT ITS HIV PROBLEM

Changsha, China -- They line up here every day, at the new Tianxin
district storefront clinic, and wait patiently for their methadone.

Among them, a man who identifies himself as Wang swirls a clear
plastic cup of lime-green liquid, brings it to his lips and swallows.

At the site of this pilot project in HIV prevention, Wang could blend
in with any of the shop owners and businessmen in this busy
commercial neighborhood of Hunan province's capital city.

He has been coming to the clinic every afternoon, since shortly after
it opened in February, hoping that methadone will break his addiction
to heroin, keep him out of trouble with the law and ultimately
protect him from AIDS.

Until recently, a scene like this was rare in China. But a
quarter-century into the global pandemic, the world's most populous
nation has begun taking cautious steps to acknowledge the peril posed
by HIV and to adopt some of the proven prevention and treatment
programs of Western nations -- such as methadone maintenance therapy
- -- to control it.

An estimated 650,000 Chinese are living with HIV, a virus that has
infiltrated the Middle Kingdom along ancient drug-trafficking routes
and threatens to spread silently into a population that still deeply
stigmatizes those who carry it.

Among those at high risk for AIDS are 120 million migrant workers,
known as the liudong renkou, or floating population. Drawn from the
impoverished rural areas where most of China's 1.3 billion people
live today, they are a source of cheap labor powering this country's
phenomenal economic expansion. Young, single and mostly male, they
live in single-sex dormitories and have ready access to drugs and prostitutes.

They also fall through the widening cracks in China's public health
infrastructure. Scenarios like these have fueled the epidemic in
Africa and India and could threaten this nation's push toward prosperity.

In 1998, China's Ministry of Health forecast that, absent a vigorous
program of prevention and treatment, 10 million of its citizens could
be living with HIV infection by 2010. Outside forecasters, such as
the Center for Strategic and International Studies in Washington,
warned of twice as many infections in the same time frame.

China has recently backed away from such dire predictions -- the
latest report written by the Chinese government and UNAIDS, the Joint
United Nations Program on HIV/AIDS, makes no estimate of future
infections. Citing more accurate surveys, it lowered from 840,000 to
650,000 -- a drop of 23 percent -- its estimate of the number of
people in China living with HIV.

The new number may, in fact, be a more accurate representation of the
epidemic's toll in China, but surveillance remains uneven, and
testing is inadequate. By the official count, there were 70,000 new
HIV infections in China last year, and 25,000 deaths from AIDS.
Nearly 80 percent of those living with HIV in the country do not know
it. By comparison, only about 25 percent of Americans with HIV are
unaware of their infection.

In Changsha, a city of nearly 1.5 million, public health leaders and
Communist Party government officials have put together a package of
prevention measures ranging from condom distribution to HIV testing
centers to new methadone-treatment clinics.

Heroin is a significant problem for China, and injection drug use is
linked to 45 percent of the country's HIV cases. Hunan province is
one of seven in China where more than 10,000 drug users are infected.

For heroin addicts like Wang, the offer of methadone treatment
carries a bitter prerequisite: To qualify for the program, drug users
must have first endured two rounds at a government drug
rehabilitation center. He said he shared a room with 20 to 30 other
addicts, and they spent months on compulsory tasks such as
bead-making. "It was, indeed, a prison," said Wang.

The 40-year-old unemployed man used to have a $60-a-day heroin habit.
Now he can tame the cravings with methadone -- an addictive opiate
itself -- for about $1.25 a day. "I think it is pretty effective," he said.

Two months after starting the program, he said his goal is to taper
off his use of methadone over two to three years and eventually to
live drug-free.

Tianxin district authorities opened the methadone clinic before a
crowd of local television reporters in February, and have been
carefully tracking its progress since. By the end of May, 72 addicts
had entered the program -- the goal is to enroll 200.

There have been setbacks. Eight participants have been thrown out
after urine tests showed they were still using heroin -- not uncommon
in methadone programs worldwide. More troublesome was a police sweep
of addicts in April. Clinic officials say the raid was incorrectly
rumored in the community to be linked to participation in the
methadone program. The result was that new monthly enrollments
dropped from 38 to 18.

Zhiyong Fu, director of the Tianxin district Center for Disease
Control, said the health department is working with police to reduce
tensions between public security authorities and drug users who want
to participate in the methadone program. He said there are also plans
to relax the requirement that addicts first stay in a rehabilitation
center before coming to the clinic, so more of them will sign up.

Changsha's HIV-prevention efforts also focus on the nighttime
entertainment industry that is burgeoning in the new China. UNAIDS
estimates that there are 127,000 prostitutes in China living with HIV
- -- about 20 percent of all cases in the country.

Across town in the Furong district, Changsha's deputy mayor Dr. Cao
Ya -- a Xiangya School of Medicine professor who spent several years
at the National Cancer Institute in Maryland -- led visitors through
the Wan Bao hotel. Here, condoms are distributed in guest rooms and
at popular karaoke salons.

"The central government has stipulated that all public entertainment
places have to have condoms," she explained.

Last year, 40 hotels in the Furong district began offering condoms in
a pilot program. Now, she said, all the hotels there are complying
with the new policy. With government subsidies, condoms distributed
through the program are either free or are sold for as little as 10 cents each.

Failure to provide condoms can, in theory, lead to fines of up to
$600, but Changsha public health administrator Peng Hongei said the
emphasis today is not on punishment, but persuasion. "It's a
process," he said. "At first, we stress self-compliance."

In Beijing, 850 miles to the north, construction workers are busily
adding a four-story addition to the You An Hospital, one of only two
medical centers in China that specialize in AIDS. It has a 20-bed
ward offering care to seriously ill AIDS patients. The new project
will expand its capacity tenfold.

The need for specialty hospitals is apparent. "Stigma is a massive
issue. Most doctors won't touch you if you have HIV," said Drew
Thompson, National Director of the China-MSD Partnership in Beijing,
a joint project between the Chinese Health ministry and
pharmaceutical company Merck.

A center for treatment of infectious diseases, You An Hospital was a
focal point during the 2003 SARS outbreak -- an occurrence that many
health officials in China credit with bringing the country out of
isolation on medical matters. Initial efforts to hide the extent of
SARS in Beijing eventually led to the sacking of the mayor and
China's health minister, but the central government now considers its
resolution of that crisis as a success story and a model for openness
about such matters in the future.

"SARS loosened them up. They found they could reveal a vulnerability
and not get criticized for it," said Dr. Eric Goosby, president of
the Pangea Foundation in San Francisco.

Another event often credited with spurring China's leaders on AIDS
was a visit by former President Bill Clinton and his public embrace
of 21-year-old HIV-positive activist Song Pengfei during a news
conference in Beijing in November 2003. After Song loudly sought
recognition, Clinton welcomed him to the podium. In front of startled
Chinese vice ministers, Clinton hugged Song and praised his courage
for identifying himself as HIV-positive.

The next month, Chinese Premier Wen Jiabao and Vice Premier Wu Yi
were seen for the first time shaking hands of hospitalized AIDS
patients in front of national news media.

China subsequently announced its Four Frees and One Care program. It
offers free HIV testing; free antiviral drugs to rural residents with
AIDS; free drugs to pregnant women; free schooling for AIDS orphans;
and economic assistance to people living with the disease.

Whether the Chinese commitment runs deeper than showcase pilot
programs and sloganeering remains to be seen. UNAIDS points out that
implementation of the Four Frees program has been "relatively poor"
in some regions. Nevertheless, there is among international AIDS
workers a sense that China is taking the epidemic seriously.

Goosby, who works with the Clinton Foundation on Chinese AIDS
projects, said a 3-year-old Pangea program in Yunnan province has
become a model of the continuum of care needed to treat a
drug-related HIV epidemic. In a province that borders the
opium-growing regions of Burma and is burdened with heavy
injection-drug use, the program provides needle exchange for addicts,
methadone for those who want it and antiviral treatment for at least
some of those who have AIDS.

It's just one more sign of measurable progress in China's newly
invigorated fight against HIV. There are now 91 needle exchange
programs and 128 methadone clinics nationwide. Central government
spending has risen to $100 million from $12 million in 2001. But of
the 75,000 officially recognized AIDS cases, only 20,000 are
receiving AIDS drugs.

China's most unique HIV problem is a cohort of villagers in Henan
province who became infected in the early 1990s through the
unscrupulous practices of commercial blood sellers -- clinics that
paid donors for plasma. They separated red blood cells from the
plasma, and then reinfused the donors with pooled red blood cells so
they could donate more frequently. But the pooled blood was
contaminated with HIV, and estimates are that 70,000 to 250,000
villagers became infected as a consequence.

Henan province's roughshod treatment of Chinese reporters who broke
the story of the infected-blood sellers is a cautionary tale and
reminder that this fast-growing nation remains a police state. At the
provincial level, there remains an aversion to bad press and media
crusades for government accountability. AIDS activists and
whistle-blowers have reason to fear. In 2002, Beijing activist Dr.
Wan Yanhai was jailed for 27 days because he published on his Web
site a Henan provincial government document about the HIV outbreak
there. He had earlier infuriated authorities there by publicly naming
government officials who allegedly were complicit in the blood-selling scheme.

Yet the international scolding endured by China for jailing Wan may
have contributed to its improved response to AIDS. In March 2003,
China launched a program to provide AIDS drugs to the infected blood
donors in Henan. Although there were problems with drug quality at
the start, it was the first step toward provision of antiviral
medicines to infected patients throughout the country.

Although China has only begun to roll out antiviral drugs for its HIV
cases, the country has already become one of the major suppliers of
the raw materials used in AIDS drugs throughout the world.

Last year, Xiamen MchemPharma Group of Xiamen cut a deal with the
William Jefferson Clinton Foundation to supply raw materials for AIDS
drugs for sale in 40 poor countries. The company provides the
chemicals to major generic AIDS drugmakers in India such as Cipla,
Hetero and Ranbaxy. The firm said it can produce enough antiviral
drugs to treat 400,000 people, and can sell the active ingredient for
AZT for 20 percent below the international wholesale price.

Desano, a 10-year-old vitamin and drug manufacturer in Shanghai,
currently makes the active ingredients for 14 antiviral drugs. It is
a major supplier to generic drugmakers in India, Brazil and Thailand.
Since 2002, it has been producing generic drugs for the domestic
market, where it now sells its own versions of the antivirals ddI,
AZT, nevirapine and d4T.

The new drug companies are typical of China's new entrepreneurial
bent: fast-growing, high tech and global in their reach. Whether
China will invest that sort of energy and expertise to deal with its
own AIDS problem remains to be seen, but the future course of the
epidemic, and the fate of millions, may turn on the answer.