BACKGROUND: Although the first case of AIDS was not officially reported until 1995, Xinjiang has emerged as China’s most infected region after Yunnan province. By the end of 2001, there were 6,029 officially reported cases of HIV/AIDS, or 22% of the national total. However, UNAIDS believes that the rate of infection may be underreported by as much as 5 to 10 times. Similar to Central Asia, the vast majority (over 90%) of HIV infections in Xinjiang are injecting drug users (IDUs) and are under 30 years of age—the most sexually active age group. Also, the epidemic is concentrated in Urumqi, Yining and Kashgar, all cities that lay along the region’s main illicit drug trading routes. Xinjiang’s geographic position along the arc of heroin trafficking between Central Asia and Southeast Asia’s Golden Triangle has unique implications for the transmission of HIV/AIDS. Drug users in Xinjiang initially smoked opium, which presents no direct risk for HIV. The further along the trafficking route, however, the more expensive narcotics become and the more economical it is to inject heroin. Xinjiang lies far enough from major production centers in Burma and Afghanistan to bring up the street value of heroin to 800 RMB per gram, a high fee that has driven up injection use. In 1999, registered drug users totaled 21,000, but some experts estimate there may be as many as 800,000 unregistered drug users presently in the region, 90% of which are IDUs. Furthermore, the WHO believes the proportion of needle sharing between IDUs in Xinjiang is 100%. Unsurprisingly then, the prevalence of HIV among IDUs is also dangerously high. Also complicating the nexus between drug use and HIV transmission are the many subtypes of the deadly virus springing up in the region. Subtype A is prevalent in Russia, B in Thailand, Burma and the rest of China, and C in Pakistan, India and Burma. A unique B/C recombinant form has been found in Xinjiang, reflecting the rapid spread across borders by injecting drug use and the rise of new HIV strains. All of this makes prevention and treatment measures highly problematic. Complex socio-economic and political factors also play an important role in the spread of HIV/AIDS in Xinjiang. Poverty and unemployment are high among Xinjiang’s minority groups. Dissident sources put the job placement rate of Uyghurs entering the work force at a mere 40%. Per capita income and government spending in Xinjiang are slightly above the national average but are higher in the cities where the majority of the Han population resides, and lower in the countryside, which is almost exclusively minorities. The lack of opportunities aggravates dissatisfaction and increases boredom and hopelessness among Xinjiang’s minority groups, leading to an overall increase in drug use and an in women commercial sex workers. The rise of HIV/AIDS infection is also the result of economic growth that has occurred in the region and with it a shift in social mores and sexual behavior. Combined with low condom use among Muslim Uyghurs, these changes have drastically raised the rate of sexually transmitted infections (STIs), which the WHO reports has increased at an annual rate of 30%. STIs in turn increase the transmission of HIV.

IMPLICATIONS: The high rate of HIV infection among IDUs makes China’s drug policies crucial to addressing Xinjiang’s AIDS epidemic. The crime rate has grown in tandem with drug use, thus the government is understandably keen to stamp out drug use. Its approach is uncompromising. Under 1997 amendments to the 1979 Drug Control Law, possession of more than 15 grams of heroin, for instance, is punishable by 15 years imprisonment to the death penalty. Treatment of individual drug users is also brisk. First time offenders are sent to compulsory detox centers for 3-6 months and re-offenders may be sent to ‘education through labor’. An emphasis on catching rather than reforming offenders pushes IDUs further underground, making prevention, surveillance and treatment efforts far more difficult. Under these circumstances, modifying IDU behavior is far more difficult and the HIV epidemic could easily spread beyond high risk populations. Antenatal women infection rates (0.5% in 1998) and transmission rates from IDUs to spouses (0.1%) indicate that HIV is moving into the general population. A rampant epidemic of HIV/AIDS in Xinjiang could also exacerbate political unrest. Exploitative policies, Han migration and repressive crackdowns against “splittist” activities have already incited Uyghur challenges to Chinese rule in Xinjiang, including violent uprisings. The spread of AIDS and its resulting vicious cycle of infection, economic devastation and social disintegration could have further destabilizing affects in the region. In addition to enormous human devastation, the rapid spread of HIV/AIDS in Xinjiang represents a grave threat to the security and stability of the region. The Chinese government has begun to act with the “Xinjiang Uyghur Autonomous Region HIV/AIDS and STD Prevention and Control Mid-long Term Plan” (2001-2010). Other initiatives, most notably the World Bank and Australia’s HIV/AIDS Care and Prevention Project are partnering with the Chinese government to increase Xinjiang’s capacity for an effective response to HIV. Whether a comprehensive and aggressive approach necessary to address Xinjiang’s HIV epidemic is finally being implemented remains uncertain. Moreover, the healthcare systems in the region are poorly positioned to stem the onslaught of the HIV/AIDS epidemic. There are few medical facilities to treat patients with full-blown AIDS, testing is prohibitively expensive, needle exchanges are nearly unheard of, and antiretroviral treatment is virtually unavailable. As HIV/AIDS moves from marginalized parts of societies into the mainstream population, national infection rates will increase dramatically and may overwhelm the system’s capacities. A strong educational and institutional framework is necessary for as program to be effective. In China, it would be more effective to have a permanent organization with high priority political and financial resources.

CONCLUSIONS: The transborder nature of the threat of HIV/AIDS, drug trafficking and the rise of STIs necessitates that China and Central Asia work together openly and honestly. Repressive drug laws simply drive addicts further underground and shift illicit heroin trade elsewhere. Coordinated needle-exchange programs, drug-treatment and culturally sensitive prevention and education activities for STIs, including HIV, are crucial. The Shanghai Cooperation Organization (SCO) could offer a forum for a harmonized approach. Yet to date, there is little evidence this is happening. At the SCO summit in January 2004, enhancing anti-drug trafficking measures was tabled but little about the region’s alarming HIV/AIDS problem was discussed. Anti-terrorism and interregional trade remain at the top of SCO’s agenda. However, without adequately addressing HIV and related issues, health security within the region will continue to undermine the goals of economic stability and national security.

AUTHOR BIO: Eric Hagt is a graduate student of international development at UC Berkeley. He lived in China for seven years and is a contributing author to the CSIS report, “China’s New Journey to the West: China’s Emergence in Central Asia and Implications for U.S. Interest”.