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Asia, East

By Mitchell Feldman, Tim Brown and Masahiro Kihara


East Asia encompasses a number of countries, including China, Taiwan, Japan, South Korea, North Korea, and Mongolia. With approximately one-quarter of the world's population, China is far and away the largest and most populous country in the region; on a per capita basis, however, Japan, Taiwan, and South Korea are far wealthier, with Japan a global economic superpower. By contrast, North Korea had, by the mid-1990s, become one of the most isolated and impoverished countries in the world.

On the surface, most of the countries of this region may seem to share little in common with regard to the AIDS epidemic other than geographic proximity. They are culturally, economically, and politically distinct and have been affected by and have responded to the epidemic in unique ways. Closer inspection, however, reveals that these countries do have much in common in terms of AIDS. Because HIV infection appears to have been introduced to East Asia later than to other world regions, the East Asian countries are all in the earlier stages of their epidemics. Epidemiological trends in most of the countries show a clear shift to a predominantly heterosexual epidemic, a pattern already observed in other countries of Asia.

Japan appears to have a relatively low prevalence of HIV infection. A number of factors may contribute to this, such as the late introduction of HIV and low-risk behavior patterns within the general population. The ministry of health and welfare in Japan initiated a voluntary AIDS reporting system in September 1984 and expanded this in 1987 to include persons found to be HIV-positive. The first officially reported case of AIDS in Japan was in March 1985: a gay Japanese national who had been living in New York was diagnosed while traveling in Japan. By 1996, almost 4,000 persons had been found to be infected with HIV in Japan, and over 1,000 AIDS cases had been reported, although the actual totals are probably higher.

Persons with the blood disorder hemophilia had been impacted far more than any other vulnerable group in Japan by the mid-1990s, accounting for approximately 55 percent of cases of AIDS and HIV infection in Japan. Virtually all of these infections have been linked to HIV-infected blood products that Japan had imported from the United States. Since 1990, this proportion has been declining amid a gradual increase in cases owing to other causes and because of an absence of any new hemophiliac HIV/AIDS cases since the introduction of heat-treated blood products in July 1985.

Japan has a large, well-established commercial sex industry consisting of both Japanese and foreign prostitutes, many from countries where HIV is much more prevalent than in Japan. Despite official concern and occasional public hysteria, prostitutes in Japan have not yet been widely affected by HIV. More troubling, perhaps, is that rates of condom use remained far below 100 percent throughout the 1990s, as evidenced by the fairly high rates of sexually transmitted diseases (STDs) among both foreign and Japanese prostitutes.

The screening of donated blood was initiated in Japan in 1987. The rate of HIV seropositivity among volunteer donors has been steadily increasing, with data from 1995 revealing a rate of 1.40 per 100,000 in Tokyo, and 0.54 per 100,000 nationwide. Of more than 100,000 pregnant women and more than 5,000 hospitalized patients screened, none had been found to be HIV-positive by 1995.

Heterosexual contact is the most common route of sexual transmission of HIV in Japan. In particular, the young heterosexual population that is at risk may be substantial. One survey found that 30 percent of men and 11 percent of women under 30 years of age reported having had sex with five or more partners in the previous five years.

HIV/AIDS appears to have had a limited impact on men who have sex with men in Japan, although no seroprevalence data are available for Tokyo, where most of the reported homosexual cases were concentrated. In fact, although nationally there has been a gradual increase in the number of homosexual cases reported to the surveillance committee, by the early 1990s, the number of cases of heterosexual transmission surpassed that of homosexual transmission in Japan. One survey of a gay bathhouse in Nagoya in 1994 revealed a seroprevalence rate of 1 percent.

The only available data on Japan's injecting drug user (IDU) population, mostly users of the stimulant methamphetamine, reveals an approximately 0.03 percent seroprevalence rate among voluntarily tested prisoners. However, needle sharing may be more common than previously thought, as suggested by the high rate of hepatitis-C virus infection in this population and by a reported needle-sharing rate of 85 percent in one study.

Early HIV-prevention efforts in Japan focused primarily on imported blood products and generally on strategies that sought to identify individual cases of HIV infection, rather than on vulnerable populations and the general population. This "offshore strategy" of attempting to prevent HIV from entering the country has gradually been replaced by a strategy that relies more on cooperation and inclusion, with an emphasis on education, voluntary testing, and counseling. Although condom use is very high in Japan, this seems to be mainly for the prevention of pregnancy, especially because oral contraceptives are available only for specific medical indications, and rates of some STDs continue to rise. This has led some observers to worry that it is only a matter of time before HIV spreads rapidly throughout the heterosexually active population.

Within the homosexual community, there have been some efforts at self-education. In addition, many bathhouses have adopted the offshore strategy and have posted signs instructing foreigners to keep out. This "no gaijin" policy may contribute to the spread of HIV over the long term by reinforcing low rates of condom use among Japanese men who have sex with other men.

With its advanced medical technology and near-universal access to health care, Japan is capable of delivering the highest quality medical care to people with AIDS. Only a small handful of health care providers and hospitals, however, have the knowledge, experience, and desire to care for patients with AIDS. In 1989, the AIDS Prevention Law was enacted, which obligates physicians to report anonymously new cases of HIV or AIDS to the local government.

Of all impacted groups, people with hemophilia have exerted the most influence on the ministry of health and welfare in setting AIDS policy. Although they are popularly seen as the "innocent victims" of AIDS in Japan, hemophiliacs have also clearly been subject to stigmatization and discrimination as a result, in part, of their association with AIDS. Hemophiliac groups have responded by organizing their members to oppose some aspects of the Japanese government's AIDS policies and, in some cases, have managed to have themselves exempted from these policies. As of the mid-1990s, the most visible action taken by hemophiliac organizations had been a massive lawsuit that they brought against the Japanese government and five pharmaceutical companies responsible for negligence in importing blood products into Japan; it was agreed that infected Japanese hemophiliacs would be paid more than the equivalent of $400,000 each.

The HIV/AIDS epidemic in China is in its early stages. However, with the world's fastest rate of economic growth, the social and economic changes sweeping the world's most populous country could produce a substantial HIV epidemic unless effective action is taken. By late 1995, almost 2,600 people infected with HIV had been identified in China, and 77 AIDS cases had been reported to the World Health Organization. This small number was in sharp contrast to neighboring Hong Kong, a former British colony (returned to Chinese control in 1997), which has traditionally had a much more open society than China. Although having only one two-hundredths the population of China, Hong Kong had by mid-1995 reported 148 AIDS cases, more than double the total for all of China.

China became part of the global AIDS epidemic when a visiting foreigner died of AIDS in Beijing in 1995, heralding China's entry into the global AIDS epidemic. Over the next several years, most infections detected were in foreigners or in Chinese returning from overseas, until the discovery in 1989 of an exploding epidemic among IDUs in the southwestern province of Yunnan. For the next few years, national attention focused on foreigners and drug users, but little attention was given to the possibility of a substantial heterosexual epidemic. As more and more cases of infection have been detected, however, the proportion attributed to heterosexual transmission has increased steadily.

Although detected numbers have been small for a population of 1.2 billion, secondary indicators point to significant potential for heterosexual spread in China. The rates of other STDs have been climbing rapidly, especially among the young. Arrests for prostitution have also been increasing, and there is frequent anecdotal evidence of a thriving commercial sex business.

Limited resources for the testing of donated blood make transmission through receipt of blood products another possibility, as highlighted in reports of infected plasma donors in rural areas of the country. These rural cases also demonstrate that a nationwide epidemic is under way, a reality supported by the detection, by late 1994, of HIV in 22 of China's 30 administrative regions.

A national AIDS committee was established in China in 1986, with a program largely focused on surveillance and research. In 1990, when a medium-term plan was adopted, the program expanded to include 22 provincial AIDS committees. This plan emphasized prevention of sexual transmission, blood screening, and epidemiological surveillance. Education efforts increased substantially in late 1995, with increased emphasis given to adolescents, as it became clear that HIV spread in China was more extensive than most people had assumed. Efforts have generally been successful in raising awareness of AIDS, but because of conservative social attitudes and concerns about condom promotion increasing promiscuity, informational materials rarely have given specific information on protecting oneself from AIDS.

Lack of political will to address what appears on the surface to be a small problem, limited knowledge of the extent of risk behaviors, low levels of budgeting for AIDS prevention, and negative attitudes toward those with HIV/AIDS are all reducing the country's ability to mount an effective response. Unlike many other countries, China does not have active nongovernmental organizations (NGOs), and this, combined with conservative government attitudes and the social invisibility of those engaging in risk behaviors, makes reaching vulnerable populations difficult.

HIV/AIDS has been covered under a number of laws. These require HIV tests for foreigners residing in China for more than one year and for returning Chinese citizens who have lived abroad, mandatory reporting of HIV and AIDS cases, restrictions on travel for those with HIV, operational procedures to prevent transmission in hospital settings, and specification of target populations for surveillance. National policy has also emphasized prevention through criminal legislation, including laws against the promotion of injecting drugs and prostitution. It is generally acknowledged that the laws are weak in specifying the rights and obligations of those with HIV and in protecting them against discrimination.

In Taiwan, as in many other Asian countries, the first individual diagnosed with AIDS, in late 1984, was a foreign visitor, with the first domestic case seen in 1986. An active surveillance program for HIV began in 1985, and through March 1996, a total of 1,078 individuals with HIV infections had been recorded. Of these, 274 had been diagnosed with clinical AIDS. Through the early 1990s, most infections identified were in homosexual men, followed by heterosexual men and IDUs. However, by the mid-1990s, heterosexual transmission had become dominant among males with newly reported infections. Most women with AIDS or HIV, who have constituted approximately 10 percent of reported HIV/AIDS cases, contracted their infection through heterosexual contact. The number of new infections identified each year has grown rapidly, increasing from 10 in 1984 to 262 in 1995.

Many of the factors contributing to rapid growth of the epidemic in other Asian countries are present in Taiwan. There is an active commercial sex industry with a number of different types of sex-work sites. With Taiwan's strong economy, sex tourism to the countries of Southeast Asia for purposes of having sex with prostitutes is not uncommon. Social stigma and negative attitudes toward homosexual and bisexual men and IDUs reduce the ability of health personnel to locate, educate, and promote condoms and safer sex to at-risk populations in these communities. Negative attitudes toward those with HIV/AIDS remain a problem, even within the health care system. Several cases of suicide have been reported among those with HIV/AIDS.

The ministry of health established an AIDS committee in 1985. Although a number of NGOs are working with AIDS, most activities have been mounted by the government with government money. These include increased HIV and STD surveillance, mass media education efforts, implementation of universal precautions in medical settings, and universal screening of blood and blood products. However, despite progress, these efforts have been hampered by the social stigma associated with HIV risk behaviors, the social invisibility of vulnerable populations, difficulties in public discussion of sex and drug use, and discriminatory attitudes toward those already infected. The increasing numbers of new infections each year highlight the urgent need to overcome these limitations.

Like the other countries of East Asia, the HIV epidemic in the Republic of Korea (South Korea) had a late start, with the first infections detected in 1985. South Korea responded to the epidemic by introducing legal requirements for extensive HIV testing of populations believed to be at risk, including sailors, hotel and restaurant workers, sex workers, prisoners, foreign laborers, and homosexual men. Through mid-1995, these efforts had detected 472 people with HIV, and the country had reported 32 cases of AIDS to the World Health Organization. Substantial HIV prevalence was seen only in homosexual men, although this was based on a small number of tests, because social stigma has made it difficult to reach these men. An upward trend was observed in sailors and in female commercial sex workers, with rates increasing tenfold between 1993 and early 1995, but the absolute rates remained low (0.07 percent in sailors and 0.06 percent in sex workers). In these detected infections, males outnumbered females by eight to one. Almost three-quarters of men reported contracting HIV heterosexually, with most others contracting HIV through homosexual contacts.

Approximately one-half of South Korean women with HIV contracted it from their husbands. This is in keeping with patterns of gender inequality observed in many Asian cultures and elsewhere, where men are relatively free to engage in premarital and extramarital sex, but women are restricted from doing so. Thus, the major risk for most women is sex with their husbands. A few small studies indicate that a substantial number of Korean men engage in commercial sex, especially when traveling and that wives accept this behavior, sometimes providing condoms for their husbands' extramarital contacts. No recent studies have addressed the prevalence of these behaviors or of preventive behaviors on a population level, so it is difficult to assess the country's potential for a large-scale epidemic. The country's response is comparatively young as well but has produced fairly high levels of awareness of HIV/AIDS. However, negative attitudes toward those with HIV and AIDS have been reported, and Korean HIV law includes provisions for segregation, compulsory detention, and restriction of employment for those with HIV infection.

No information is publicly available on the epidemic in the Democratic People's Republic of Korea (North Korea), which is probably the most closed society in the world. This lack of information is most likely related to a failure to diagnose and report rather than to the absence of HIV, although the country's comparative isolation may have delayed initial entry of the virus. The geographically vast but sparsely populated country of Mongolia had reported no AIDS cases by mid-1995, but this was also likely to represent an undercounting.

Overall, although the cultural, political, and economic differences among the countries of East Asia are substantial, these countries share common behavioral characteristics and rapid social and economic changes, all of which contribute to the potential for extensive HIV spread. The late entry of the virus into the region has presented these countries with a major opportunity to prevent the spread of HIV, but it remains to be seen whether this opportunity will be maximized.

Related Entries:

Asia, South; Asia, Southeast; Asian and Pacific Islander Americans; Buddhism; Chinese Medicine

Key Words:

East Asia, Pacific rim, [individual countries by name]

Further Reading

Brown, T., and P. Xenos, "AIDS in Asia: The Gathering Storm," Asia-Pacific Issues 16 (August 1994)

Chen, M.-Y., G.-R. Wang, C.-Y. Chuang, and Y.-T. Shih, "Human Immunodeficiency Virus Infection in Taiwan, 1984 to 1994," Journal of the Formosan Medical Association 93 (1994), pp. 901-905

Chung, K. K., "Current Status of the Acquired Immunodeficiency Syndrome Prevention Act of the Republic of Korea," in HIV Law and Law Reform Asia and the Pacific, New Delhi: UNDP Regional Project on HIV and Development, edited by D. C. Jayasuriya, 1995, pp. 231-234

Feldman, E., and S. Yonemoto, "Japan: AIDS as a Non-Issue," in AIDS in the Industrialized Democracies, edited by D. L. Kirp and R. B. Bayer, New Brunswick, New Jersey: Rutgers University Press, 1992

Kaldor, J. M., W. Sittitrai, T. J. John, and T. Kitamura, eds., AIDS in Asia and the Pacific, special supplement to Journal of Acquired Immune Deficiency Syndrome (1994)

Kihara, M., S. Ichikawa, M. Kihara, and S. Yamasaki, "Descriptive Epidemiology of AIDS/HIV in Japan," AIDS in the US and Japan, special supplement to Journal of Acquired Immune Deficiency Syndrome

Li, V., B. Cole, S. Zhang, and C. Chen, "HIV-Related Knowledge and Attitudes Among Medical Students in China," AIDS Clinical Care 4 (1993), pp. 305-312

Salzberg, S. M., "The Japanese Response to AIDS," Boston University International Law Journal 9 (1991), p. 243

Wu, Z, Z. Liu, and R. Detels, "HIV-1 Infection in Commercial Plasma Donors in China," Lancet 346 (1995), pp. 61-62

Yang, B.-M., Y.-O. Shin, and M.-H. Choi, "Impact of HIV/AIDS on People and Households: Korea," presented at the 1994 Finalization Meeting of ADB/UNDP Study on the Economic Implications of the HIV/AIDS Epidemic in Selected DMCs

The Encyclopedia of AIDS: A Social, Political, Cultural, and Scientific Record of the HIV Epidemic, Raymond A. Smith, Editor. Copyright © 1998, Raymond A. Smith. Carried by permission of Fitzroy Dearborn Publishers.

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