ILLNESS, CRISIS & LOSS, Vol.

18(2) 129-146, 2010

WOMEN, POVERTY, AND THE EPIDEMIC

IN CHINA: CASE STUDIES ON RURAL PEOPLE
LIVING WITH HIV/AIDS*

XIYING WANG, PH.D.

XIULAN ZHANG, PH.D.

YUEBIN XU, PH.D.

YURONG ZHANG, PH.D.

Beijing Normal University

ABSTRACT
Based on in-depth interviews with 110 People Living with HIV/AIDS
(PLWHA), this qualitative study is a preliminary endeavor to delineate
the socio-cultural scripts of rural PLWHA in China including their illness
experience, everyday lives, and strategies of coping with stigma, poverty, and
social barriers. This study documents the new wave of the “feminization
of HIV/AIDS” in China. There is a gender difference of infection routes.
Women were infected through heterosexual contact much more frequently
than men. This study also discusses power struggles and gender asymmetries
between rural couples living with HIV/AIDS, especially on the issues of
“disclosure of the illness” and “condom negotiation.” Even when the disease
has changed the family structure and women become the main financial

*This publication is supported by the Alliance for Health Policy and Systems Research, an initiative
of the Global Forum for Health Research in Collaboration with the World Health Organization.
This study is also supported by China Gender Facility (Project no. 00040647), United Nations
Development Fund for Women (UNIFEM). This publication is an output of the POVILL Project,
supported by the Sixth Framework Programme of the European Commission.

129

Ó 2010, Baywood Publishing Co., Inc.

doi: 10.2190/IL.18.2.d
http://baywood.com
130 / WANG ET AL.

supporters, gender inequality within a family is not changed in that women

remain not the main decision makers and continue to suffer most from
poverty. In conclusion, this article locates women’s HIV-related experience
within the social ecology of HIV/AIDS, and explores how gender inequality
intersects with traditional customs and ethics, economic and political policy,
medical system, and patriarchal values to heighten women’s vulnerability
to both the illness and poverty.

Key Words: HIV/AIDS, gender, poverty, China

INTRODUCTION
Based on in-depth interviews with 110 People Living with HIV/AIDS (98
PLWHA and 12 uninfected people with infected family members), a qualitative
study was conducted in China with three purposes in mind:
1. to illustrate the socio-cultural scripts of everyday lives of rural PLWHA,
their families, and their communities;
2. to describe the increasing feminization of the HIV/AIDS epidemic and
feminization of poverty within HIV/AIDS families; and
3. to explore how gender inequality intersects with traditional customs and
ethics, economic and political policy, and patriarchal values to impact
PLWHA and their families’ lives.
The purposes of this study were determined based on the following three con-
siderations:
1. the national HIV/AIDS epidemic and increasing feminization of HIV/AIDS;
2. the intersection of HIV/AIDS and poverty; and
3. a change in focus from a biomedical to a gender perspective, which offers
a new way of understanding the disease and people living with it.
Although the epidemic started later in China than in other parts of the world,
such as Africa, and although its prevalence among the general population is still
relatively low in China, high prevalence rates have been reported in selected
locations and/or populations. For example, in provinces along drug-trafficking
routes, the HIV prevalence rate exceeds 20-30% among intravenous drug users. In
central China, where formerly commercial blood/plasma donation was prevalent,
the rate among blood/plasma donors reached an average of 10-20%, with rates as
high as 60% in some communities. HIV/AIDS continues to have a large impact in
China and places a heavy burden on the state, economy, families, and social
networks.
The feminization of HIV/AIDS has become a trend of the HIV epidemic around
the world. From a global perspective, the experience in most countries is that
 WOMEN, POVERTY, AND HIV/AIDS IN RURAL CHINA / 131

women, especially those who are marginalized, have been pushed from the edge
into the center of the AIDS crisis (Hu, 2006). From 1985 to 2005, the percentage
of women infected with HIV/AIDS among the whole infected population has
ascended rapidly around the world, having risen from 35% to 46%, to as high
as 60%, among young women aged from 15 to 24. As of the end of 2005,
women older than 15 years of age represented more than 17.30 million of the 38.60
million people living with HIV/AIDS worldwide (UNAIDS & WHO, 2006).
In China, the feminization of HIV/AIDS is an ongoing characteristic of the
progression of the HIV epidemic. The problem of growing numbers of women
living with HIV/AIDS has grown more evident and more serious. Since China
documented its first case of AIDS in 1985, the number of women infected with
HIV/AIDS has increased rapidly. According to the 2004 Report on China
HIV/AIDS Prevention and Control Assessment by the State Council AIDS
Working Committee Office and UNAIDS, the percentage of women infected with
HIV/AIDS among the whole infected population increased from 15.3% in 1998
to 39% in 2004 (State Council AIDS Working Committee Office & UNAIDS,
2004). As of the end of October 2009, the number of people in China reported
to have been infected with HIV/AIDS totaled 319,877, of which 102,323 were
AIDS patients and 49,845 were deceased. However, the actual figure of those
infected may be much more than that in the national statistics, as the national
report estimates that only 20% of this population was reported (State Council
AIDS Working Committee Office & UNAIDS, 2007), the percentages for men
and women have a certain significance as a reference to understand gender
distribution. In 2007, among the reported HIV-infected people, 71.3% were
men and 28.7% were women; among the reported AIDS patients, 60.6% were men
and 39.4% were women (State Council AIDS Working Committee Office &
UNAIDS, 2007).
The intersection of HIV/AIDS with poverty is another important feature of
China’s HIV epidemic. The relationship between HIV/AIDS and poverty is one
of mutual causality: poverty correlates with many of the high-risk behaviors
associated with HIV/AIDS—for example, the selling of blood, sex work, and the
abuse of injection drugs. On the other hand, infectious disease draws many
families into the abyss of poverty (Jin, Tang, Zhao, & Lu, 2004).This strong
association of the HIV epidemic with poverty can be illustrated by the following
two findings:
1. in terms of geographical distribution, China’s HIV epidemic is concentrated
in poor rural areas; and
2. the majority of HIV-infected and AIDS patients are peasants and migrant
workers, their common characteristic being relative poverty (Li & Tang,
2005).
Moreover, areas with high HIV/AIDS infection rates are primarily the same
areas that have high rates of poverty and a vast poor population.
132 / WANG ET AL.

Social science research in China has recently begun regarding HIV/AIDS as a

social problem. For a long time, the biomedical approach dominated the study of
HIV/AIDS, which is deeply related to two issues: on the one hand, the state has
long defined HIV/AIDS as a contagious disease with high death rate rather than
as a social problem; on the other hand, the state initially ignored the existence
of the epidemic and characterized HIV/AIDS as a foreign disease associated
with a Westernized lifestyle. Recently, this attitude has started to change in the
direction of a more practical and realistic one.
Replacing the biomedical approach with a gendered perspective means that
we not only regard HIV/AIDS as a serious contagious disease, but also as a
socio-economic problem that intersects with gender inequality. Some scholars
have already done some works in this direction. For example, Lin et al. (2007) did
a comprehensive literature review on women’s vulnerability to HIV/AIDS and
drew the conclusion that women were more vulnerable than men to HIV infection,
according to eight determinants: biology; society and culture; violence against
women; laws; education, knowledge, and skills; poverty; migration; and stigma
and discrimination. Zhou (2008) did a qualitative study on HIV-infected women’s
illness experience, and examined the interactions between HIV/AIDS and gender
roles in the Chinese context. She found that HIV infection has created a conflict
between women’s intention to fulfill their conception of “womanhood” and
a decreased ability to do so, which, in turn, has adversely affected their self-
perception and well-being. These studies provide a wonderful platform to start
with, and this study will embody extreme interest in how gender intersects with
the social ecology of HIV/AIDS, including the eight determinants—and, on the
macro-level, in traditional customs and ethics, economic and political policies,
and patriarchal values—to create multiple oppressive systems that significantly
impact rural women living with HIV/AIDS.

METHODS
Data collection was carried out between December 2006 and April 2007. The
research team included three research professors and 10 postgraduate students
(eight female and two male). Most interviews were conducted by students who
were trained in in-depth interviewing beforehand by research professors. They
interviewed 110 informants from 4 different provinces, from 6 cities, 11 counties,
14 towns, and 5 Methadone Maintenance Treatment Clinics.
According to national statistics, more than 70% (PLWHA) live in the rural
area (State Council AIDS Working Committee Office & UNAIDS, 2004, 2007),
which is the main reason for selecting rural areas in Yunnan, Henan, Anhui, and
Guizhou provinces as research sites. These four provinces have high rates of
infection and are relatively poor in comparison to the average for the whole nation.
At the end of October 2007, six provinces—namely Yunnan, Henan, Guangxi,
Xinjiang, Guangdong, and Sichuan—were reported as having 80.5% of the
 WOMEN, POVERTY, AND HIV/AIDS IN RURAL CHINA / 133

PLWHA in the nation, while Henan, Yunnan, Guangxi, Anhui, Guangdong, and
Hubei were reported as having 83.0% of the AIDS patients in China (State
Council AIDS Working Committee Office & UNAIDS, 2007). Moreover, the
four provinces chosen represent different routes of transmission. In Yunnan
and Guizhou, intravenous drug use (IDU) is the predominant route, while in
Henan and Anhui, commercial blood/plasma donation (CBD) is the main source
of transmission.
It was difficult to identify informants, since the issue of HIV/AIDS remains
sensitive in China. With the collaboration of the Ministry of Civil Affairs and the
local department of civil affairs, however, it was relatively easy for the research
team to identify informants in Henan and Anhui, since most PLWHA have been
infected through selling blood and lived close to each other, even in the same
villages. However, in Yunnan and Guizhou the research team encountered huge
difficulties in identifying potential informants, as PLWHA infected by IDU
are more afraid of moral judgment and social isolation—even local Departments
of Civil Affairs had limited information about the local HIV epidemic. In addition,
in these areas, people lived dispersed, and transportation was limited. However,
the research team developed many ways to identify interviewees in addition
to reliance on the help of the local Departments of Civil Affairs, including
reliance on:
1. village residence committees;
2. PLWHA self-help organizations;
3. some NGOs fighting HIV/AIDS;
4. Methadone Maintenance Treatment Clinics; and
5. introduction by other interviewees.
One hundred ten participants, including 50 males and 60 females, with ages
ranging from 16 to 79, were involved. There were 12 uninfected interviewees
in all—3 males and 9 females—who had a family member or members infected
with HIV/AIDS. Among the 98 PLWHA, there were 47 men and 51 women.
In-depth exploratory interviewing was used as the main method of data collection,
emphasizing the exploration of the informants’ personal histories and subjective
experiences associated with the illness from a gendered perspective. Generally,
after informed consent was received, an interview was conducted in Mandarin
Chinese, of 1 to 2 hours duration, and conversation was related to all aspects of
family life affected by the illness, including the possession and distribution of
family resources, family planning, sexual relations, reproductive health practices,
family gender roles, and social support networks. Audiotaping was avoided to
ease informants’ unwillingness, in consideration of the sensitivity of the topic.
Researchers took detailed notes during the interviews and made field notes, and
recorded dialogues, observations, and self-reflections immediately after each
interview, as part of the compilation of data for analysis. Ethical approval was
obtained from the research ethics committee in Beijing Normal University. In
134 / WANG ET AL.

order to protect the participants’ privacy, all names remain anonymous and
have been replaced by figures. Within the text, “Y,” “A,” “H,” and “G” represent
Yunnan, Anhui, Henan, and Guizhou, respectively.

RESULTS

Stigma, Poverty, and Social Barriers

HIV/AIDS is closely related to physical suffering and pain, stress, anxiety,
stigma, discrimination, and family conflict and change. Uninfected people may
not be able to imagine what AIDS patients have to suffer. For example, during
one interview, Y19 kept scratching a sore on his head, which had festered.
He narrated in an easy tone:
When my head is too itchy, I will ask my wife to scrape the head with a
knife or splash some Panaplate [a type of pesticide] on it. Although it hurts
a lot, the itch stops. (Y19, Male, 30)

The HIV/AIDS-related stigma that prevails in their lives comes from a powerful
combination of fear and shame. A11’s story demonstrates vividly how her family
life was influenced by HIV/AIDS-related stigma and discrimination:
Both my husband and I were infected through selling blood. We have one
daughter and two sons who are all healthy. We used to live in “A” Village;
however, the villagers fear the disease and they discriminate against us
greatly since we were the only family with AIDS sufferers in the village.
Therefore, we had to move to “B” Village to live in a rented house. The rent
is not a small expenditure for the family and the loneliness of living in a
new environment is also a source of stress. My husband was hospitalized
at the end of 2006 in rather poor condition. The children have dropped out
of school, as they fear being laughed at. Without farmland, we cannot earn
money by farming. Our income cannot meet the expenditures. Life is just
so hard. (A11, Female, 45)

This family encountered many of the difficulties and obstacles experienced by

other informants. Six informants reported that their child(ren) had to drop out of
school; five participants reported that it was difficult for infected people (and
sometimes even for healthy people from high infection areas) to find jobs. Seven
infected parent(s) reported that their illness influenced their uninfected adult
children’s chances of getting married, since no one wanted to be closely involved
with their families. Almost all informants believed that their social networks had
become very narrow. Seven of them reported that it was hard for them to provide
for their families by working for themselves because they could not get any help
either from banks or from other people.
It is clear that the stigma and discrimination associated with HIV/AIDS has
major social repercussions for PLWHA. In fact, the stigma is so strong that seven
 WOMEN, POVERTY, AND HIV/AIDS IN RURAL CHINA / 135

out of the 98 PLWHA preferred to bear the stress and anxiety all alone and keep
the fact that they were infected secret, even from spouses or parents. For example,
G5, single, did not tell his parents about the illness. He said,
As long as I did not tell them, it could not affect my family relationships,
daily life, and social relations.(G5, M, 30)

Poverty is usually central to the lives of PLWHA. For example, in China

electricity is a basic need for people’s everyday lives, but A17 (M, 36) used a
kerosene lamp instead of an electric lamp at night in order to save money. As
he said, “Anyway, I do not have any electronic machines.”
The link between poverty and illness has been a recurrent theme throughout
the history of public health discourses. Even in the late 19th century, Friedrich
Engels looked at the social origins of illness and analyzed the link between
the spread of infectious diseases and poor housing conditions, bad sanitation,
and overcrowding (Patna & Rifkin, 2007). In this study, we find that HIV/AIDS
often acted as the most common trigger for a downward spiral that not only
lead to impoverishment but also became an obstacle to breaking out of the
cycle of poverty.
The following three cases have been selected from the total of 110 to illustrate
in detail how the combination of gender inequality, poverty, and mobility impact
the everyday lives of PLWHA and their families. They articulate the subjective
experiences of PLWHA, the dilemmas and challenges they face in their daily
lives, and their coping strategies, and thereby reveal the residue of patriarchy
and the root of gender inequality embedded in their individual experiences.
These three cases have also been chosen to illustrate the socio-cultural scripts
of PLWHAs’ everyday lives associated with HIV/AIDS. They also exemplify
the power struggles within couples infected by HIV/AIDS and other issues,
including transmission routes, disclosure of the illness, and condom negotia-
tion, as well as other important social consequences such as family change,
the feminization of HIV/AIDS, and the feminization of poverty within families
living with HIV/AIDS.

Case One: My wife does not know that I am HIV positive

Y2, male, age 48, with a primary school education. He has a long history
of injection drug use and was confirmed as HIV-positive by the local CDC
in 1996. His ex-wife was infected through marital sex and died of AIDS
a few years ago, and his current wife does not know about his HIV status.
When asked about his sexual relationship with his current wife, he said
ambiguously that he used condoms given by the epidemic station. His
wife has never been tested for HIV and it is not known whether she is
infected or not. The village cadre, who knows his situation but is keeping
his secret quiet all the same, tell us “his wife would not marry him if she
knew about his illness.
136 / WANG ET AL.

Transmission Routes

We found that routes of infection differed between men and women. In

Yunnan, 17 of 20 men were infected through active behavior related to IDU,
while all women were infected through participation in heterosexual sex within
marriage and/or courtship. In this situation, the “safest” sex—that within the
context of a monogamous marriage—ironically turns into a source of illness,
and women become passive, innocent victims. Women are disproportionately
affected by HIV/AIDS through sexual transmission because women are bio-
logically more susceptible to HIV/AIDS than men. Also, HIV/AIDS has more
severe health consequences for women than for men, as studies have demon-
strated (Harvey, Beckman, Gerend, Bird, Posner, Huszti, et al., 2006). In statistics
about reported PLWHA from January to October 2007 in China, heterosexual
sex (37.9%) had become the most common route of transmission, with more
and more women being infected, while IDU (29.4%) was listed as the second
most serious route of transmission (State Council AIDS Working Committee
Office & UNAIDS, 2007). This shift marks how women have become more
vulnerable, and signals that the Chinese HIV epidemic has entered a new era,
that of the “feminization of HIV/AIDS.”
In Henan and Anhui, the situation was different from that in Yunnan: all
men were infected through the sale of their blood, while 22 of 27 women were
infected from selling blood and the other 5 were infected through sexual contact.
One point to note is that in Henan and Anhui, infected women who had sold
blood preferred to identify CBD as the transmission route, at the same time
neglecting the overlap of CBD and sex. Only among those who had no experience
of selling blood, sex is identified as the route of infection.

Disclosure of the Illness

HIV serostatus disclosure provides potential benefits to infected persons, their

partners and communities. However, the rates of serostatus disclosure are not
encouraging. In developing countries, rates of sharing HIV test results by men
with their sexual partners ranged widely, from 16.7% to 86%, depending on
the time frame for disclosure and different populations (Yang, Li, Stanton, Fang,
Lin, & Naar-King, 2006). Y2 did not tell his wife about his HIV status, and
this finding was not exceptional in our research:
My husband was diagnosed with HIV in 2001, but he did not tell me and
did not take any protection until 2004; the staff at CDC told me to have the
HIV test done and I found that I am already infected. (G10, female, 33)

This helps to illustrate the finding of Li et al. (2007)—that women are more
inclined to disclose their illness to their spouses and partners than men—on
the basis of self-reports, it took an average of only one day for both female
IDU and female non-IDU participants to disclose their status to others, whereas it
 WOMEN, POVERTY, AND HIV/AIDS IN RURAL CHINA / 137

took 30 days for male IDU participants and 6 months for male non-IDU par-
ticipants to disclose.
In the United States, HIV confidentiality guidelines recommend that health
professionals should not divulge personal information to others in ways incon-
sistent with the client’s original consent (Li et al., 2007). In China, confidentiality
has not been articulated into policy. The local procedures are as follows: the local
CDC informs the PLWHA and lets them decide whether or not to inform their
spouses/partners, and who will disclose the information. The Li et al. (2007) study
shows that women chose to disclose to a husband or boyfriend out of a sense of
responsibility. In Henan and Anhui, where the infection is transmitted through the
selling of blood and the infected groups and communities are highly concentrated,
disclosure to the spouse encounters less resistance. In Yunnan and Guizhou,
however, where there is more than one source of infection and injection drug use
and commercial sex bear stigma and shame, disclosure becomes more difficult.
The intersection of the medical practice of confidentiality and a patriarchal
system protects the privacy needs of men living with HIV/AIDS, while at
the same time it disrupts women’s rights to autonomy and health. In order to
reduce this phenomenon, the civil service system could establish a compulsory
disclosure policy between marital couples and couples before marriage regis-
tration when one of the partners has become infected with HIV/AIDS. In the
long term, such a policy would serve to prevent the spread of the epidemic to
women and children.

Condom Negotiation

In case one, Y2 said ambiguously that he used condoms provided by

the epidemic station when having sex with his wife. The uncertain expression
suggested that condoms were only used intermittently and they have had
un-protective sex in their daily lives. It was clear from the way that Y2 said it
that Y2 knew that condom usage would reduce the risk to his wife of becoming
infected—and yet he sometimes chose not to use a condom. The report on
HIV/AIDS Knowledge, Attitude, and Behavior among Chinese Citizens (2004)
by the Ministry of Health pointed out that, in rural areas, “often using condoms”
represented 5.4% of respondents and “seldom using condoms” represented 71.5%
of those surveyed. The results of this study are similar to those of the 2004 report.
When one partner becomes infected, especially when men are the infectors,
condom usage is very limited. This is the direct cause of women becoming
infected in the “safest” monogamous marriages and courtships.
Another reason for not using condoms is that men want to have children.
G1 (M, 35) tested HIV-positive in 2002, yet he stated clearly in the interview
that he did not take any action regarding safe sex because he wanted his own
kids so much:
138 / WANG ET AL.

I am very dissatisfied with the local CDC. I want to have my kids very
much, especially since I was confirmed as HIV-positive. I know that some-
body in my situation also gave birth to a son. When I counseled with the
local CDC, the staff said abruptly that I could not.

It seems that he did not understand clearly—or perhaps he did not care
enough—that his behavior, associated with the old patriarchal thinking of
“continuing the family line by producing a male heir,” was putting his wife’s
health and life at risk. During the field work, we noticed that the local CDCs
usually were in charge of condom distribution, but that generally condoms were
just left in a corner of the CDC or MMTC offices, where the PLWHA could
take them by themselves if they wanted to. In some CDCs and MMTCs, the
staff would ask the PLWHA to register if they took some condoms. Local medical
professionals also told us that condom usage was not as ideal as hoped for,
even though they were provided free of charge.
Because the use of condoms involves interaction with another person and
requires the participation, or at least cooperation, of both members of a sexually
active couple, interpersonal power and relationship factors are prominent in
understanding the negotiation of condom usage. Sometimes “love and com-
mitment” is used to justify the decision not to use condoms. For example, G3
(F, 38) got married even though she knew that her husband was HIV-positive.
As she told us:

At that time, I was in deep love, I was crazy, loved him, and did not consider
anything else. It was an urge to have sex, though I knew that sex is the route
of transmission. Besides, he did not offer to take any protection actively.

Later, she became infected, and she experienced deep regret, especially when
she found that her husband had had an extra-marital affair. Studies have shown
that correct and consistent condom use provides a high degree of protection
against HIV (Scott-Sheldon, Marsh, Johnson, & Glasford, 2006). However,
according to Harvey et al. (2006), women who were more committed to their
partners reported less positive attitudes toward condom use and lower perceived
vulnerability to HIV/AIDS. Lower perceptions of susceptibility to HIV/AIDS
were in turn associated with less favorable attitudes toward using condoms.
Moreover, women who had been with their sexual partners for longer periods of
time held less favorable attitudes toward condoms and lower perceived partner
norms for using condoms. It is more likely that in a patriarchal society, although
women have the potential to put a halt to unprotected sex by insisting on
condom use, they do not always exercise this power. Therefore, it is urgent
that women be educated and empowered—especially those with husbands
(sex partners) living with HIV/AIDS or at high risk of contracting HIV—with
knowledge about HIV transmission and the power of condom use negotiation in
order to protect their health and well being.
 WOMEN, POVERTY, AND HIV/AIDS IN RURAL CHINA / 139

Other Gender Asymmetries

Related to this case, we found another legacy of patriarchy, especially in rural

Yunnan. When men are infected, for whatever reason, the uninfected wives
usually devote themselves to taking care of them and sometimes risk their lives to
get pregnant and give birth. The common result is that the wives quickly become
infected. However, when women are infected, the uninfected husband usually
asks for a divorce; even when the husbands are reluctant, their parents take
action to push them to get a divorce. If women become infected through selling
blood, their situation is better, but if they get infected through extramarital sex,
divorce seems to be their only option. For example, Y12 (F, 25) became infected
through extramarital sex. Her husband went for an examination and was found
to be HIV-negative, and they divorced immediately.
The different ways men and women living with HIV/AIDS are treated
illustrates how gender inequality is deeply embedded in the patriarchal family
system. There is greater moral tolerance of men living with HIV/AIDS, while
there is more discrimination toward women living with HIV/AIDS.

Case Two: I have to support the whole family

Y29, female, age 57, Han nationality. There are five people in her family:
she, her husband and their three sons. The three sons are all addicted to
drugs and infected with AIDS. The sons sold all of the family’s savings,
property, and farmland to pay for drugs. As a result, the family owns
no farmland and therefore has no agricultural income. At the time of the
interview, two of them are still in work camp for drug rehabilitation and the
other one stays at home with nothing to do. The three sons are all single.
The eldest son was married before, but his wife could not stand him and
left, and their son, Y29’s grandson, died at an early age from an unexpected
illness. Her husband contracted cerebral apoplexy in 2005 and has been
in bed ever since. He could not work, but he kept on drinking every day.
If no alcohol was available, he would make all kinds of trouble. The whole
family relies on Y29’s hard work—selling dumplings and rice noodles at
the market every morning.

Women as Main Supporters

In the past, the existence of gender inequality in China often led to the
conclusion that men were the main supporters and contributors in the family.
This case, and many others that we encountered in our fieldwork, illustrates
how women become the main supporters of the whole family when men living
with HIV/AIDS lose their capacity to work. However, even in this situation,
the traditional belief that men are superior to women is still dominant in the
process of family planning, and gender inequality within a family has not changed,
in that women have not been the main decision makers.
140 / WANG ET AL.

Gender inequality is deeply associated with local ethics and customs in Yunnan.
Even back in 1945, Xiaotong Fei and Zhiyi Zhang (2006) pointed out that during
their fieldwork in Lu Village, Yunnan, the local custom was that women work
hard while men remain idle during the day. As they describe,
Even in rich families, women and girls work in the field regularly . . . it
seems unfair that foot-bound women work industriously in the mud and
men are idling their days off.

During our fieldwork, we noticed that the current family life scripts are similar
to those of 60 years ago: women work very hard while men relax, often by
using drugs, though back that time, it was opium. Some women, both wives
and mothers, told the interviewers directly: “Since he is infected by the illness,
if drugs use can make him relaxed and comfortable, let it be.”
Fortunately, in the case of Y29, the husband did not infect his wife with
HIV. However, in some other cases, even when the women were infected, they
were still the caregivers and family supporters. For example, A4 is a 37-year-old
female infected with HIV through selling blood. The whole burden of supporting
the family is shouldered by her because her husband has chronic bronchitis and
arthritis and cannot do any physical labor or work outside the town. Her elderly
mother-in-law has high blood pressure so she cannot work either. Both children
are at school.
I work as a painter and earn 800 RMB per month. During the busy farming
season, I come back home to sustain the family’s daily life. People would
assume that my husband would show his appreciation in return for my
hard work. But when I was diagnosed with HIV, my husband asked for
a divorce immediately. However, the villagers, many of them Buddhist
believers, persuaded him to stay with me. He remains somewhat indifferent
to me. (A4, F, 37)

Feminization of Poverty

Mainstream poverty measures assume an equal distribution of poverty within

a family. From a gendered perspective, this hypothesis should be revised as
follows: a gender hierarchy of poverty exists within the family (Wang & Ci,
2005). Specifically, the gender difference means that within a poor family, when
comparing women and men, we need to examine who eats better, who wears better
clothes, who spends more, and who gets more educational investment and career
training, etc. During our fieldwork we found that, in families with PLWHA,
women often turned into the main supporters of the family, while at the same
time they became the worst victims of the family’s poverty. In the above case,
Y29 is the main supporter of the family, but she has to obey her husband, and all
the money earned by her hard work is wasted by her sons’ addiction to drugs and
her husband’s addiction to alcohol. There was no money left for her.
 WOMEN, POVERTY, AND HIV/AIDS IN RURAL CHINA / 141

Wei and Hui’s (2005) study on the reproductive health of rural women in central
Gansu province finds that it takes 3 months, on average, for an adult woman to see
a doctor after the emergence of the illness, 1 month longer than for an adult man. It
takes 48 hours for a girl to see doctor, while a boy sees a doctor within 24 hours.
Our study also finds that if both husband and wife are PLWHA, when the money
is limited, men always have the first priority in seeking medical help. Women’s
biological vulnerability, the traditional belief that men are superior to women, and
the reality of poverty within HIV/AIDS families together create a huge barrier to
women’s awareness of their own health and result in the feminization of poverty.

Case Three: I have no home where I can live

A10, female, age 23. Her husband died of AIDS half a year ago, and she is a
mother of two little girls, six and two. She is also HIV-infected through sexual
intercourse. Her husband’s family worried that she would infect other family
members, so they did not allow them to live with them. She has no choice but
to live in the county hospital with her two children. Feeling sorry for her, the
hospital exempts her from charges for water, electricity, and rent. She lives on
the subsidy of 150 RMB per month. Her maternal home is far away in Gansu
Province, and she has no money to travel back. She says she cannot imagine
how the children will survive after she dies. She says she does not want to
leave the world at such a young age, as tears flow down her cheeks.

We can understand A10’s story through the perspective of patriarchy and

the in-law conflict, and tend to criticize the mother in-law’s actions. However,
HIV/AIDS makes it even worse. Deep down, this incident of A10 and her two
children’s homelessness stems from the living arrangement of women after
marriage. In China, married women are used to leaving the maternal home and
living with their husband’s families. This living arrangement is one of the impor-
tant symbols of gender inequality in rural areas, and is closely related to rights of
inheritance, property, and farmland. Lacking these rights prevents rural women
from empowerment and sustainable development.
After the husband’s death, the direct reason for A10 and her children becoming
homeless was that she had lost rights of inheritance and farmland, and therefore
had no bargaining power to deal with her in-laws. In rural areas, villages with
limited land usually refuse to increase farmland for families that just have a
daughter in-law, while they immediately grab the farmland in families when
a daughter gets married (Bossen, 2002; Jacka, 2006); thus women lose their
entitlement to farmland as soon as they get married. This very common practice
in rural economies further marginalizes married women and worsens women’s
poverty. During the fieldwork, we noticed that many drug users sold their
farmland, without their wives’ agreement, for money for drugs. The matter is
often conducted in secret, with the women kept in the dark, since a woman’s
consent is not necessary for these kinds of transactions. For example:
142 / WANG ET AL.

My husband died of AIDS in 2004. He took drugs a lot. He left me as an

AIDS-infected widow with two children. He sold our farmlands to others,
and I cannot get it back. We three have almost no income. Fortunately,
sometimes the local department of civil affairs and the women’s federation
offer help. I do not feel well all the time—one time I passed out at the
front gate of my house and was found and saved by others two days later.
(Y30, F, 40)

Living arrangements after marriage constitute the basis of discrimination

against women and strengthen the traditional sexist custom of “regarding men
as superior to women.” Here, we notice that both of A10’s children are girls,
and this may be another reason that A10 is isolated in her in-law family. During
the fieldwork, we noted that there were many cases of widows living with
HIV/AIDS with their in-law families facing discrimination, but A10’s situation
was one of the most difficult. One of the reasons for this is that other widows
have sons, and their in-law families would not expel the mother, in consideration
of the welfare of their grandsons. For example:
At the time of interview, Y39 (F, 25), an infected widow, kept crying.
Her plight at home was poor and her parents-in-law kept burdening her
with their problems. According to the village doctor, one of the main reasons
her parents-in-law are keeping her at home is the existence of the grandson,
and because Y39’s dead husband was her parents-in-law’s only son.

For a long time, research on the Chinese rural community emphasized that
the rural community has a strong sense of geographic boundaries and is a highly
cooperative and integrative community (Bossen, 2002). The inner solidarity
relies on both the unity of families and patriarchal clans, and on the exclusion
of outsiders. A10 is an outsider, a woman, and HIV infected, and therefore she
endures multiple discriminations from the community.

CONCLUSIONS
This study is a preliminary endeavor to delineate the socio-cultural scripts of
rural PLWHA. It documents the new wave of the “feminization of HIV/AIDS”
that characterizes the Chinese epidemic and examines the impact of the com-
bination of biological vulnerability and a gender-based power structure on
people, especially rural women, living with HIV/AIDS. Based on the discussion of
power struggles between marital couples—including topics such as transmission
routes, disclosure, condom negotiation, and divorce disturbances—this study
further demonstrates how HIV/AIDS challenges family structures and stability,
makes women both caregivers and family supporters, and exposes the reality of
the feminization of poverty within HIV/AIDS families. In the end, this study sheds
light on the poverty experienced by infected women, which is due not only to the
severity of this contagious disease, but also to their living arrangements, lack of
 WOMEN, POVERTY, AND HIV/AIDS IN RURAL CHINA / 143

rights of inheritance and farmland, and the traditional belief that “men (are)
superior to women.”
The findings of this qualitative study cannot be generalized across the whole
nation, especially as it focuses on rural HIV/AIDS groups who have been mainly
infected by injection-drug use and the selling of blood. The next step in this
study will involve an extension from the rural to the urban, and pay attention to
other high risk groups, including those of gay communities and of sex workers.
However, this study has several implications for HIV/AIDS prevention, and
for interventions that focus on improving the quality of life for PLWHA and
their families.
Given the pervasiveness of HIV/AIDS infection within the heterosexual
community, determining avenues for improving safer sex is critical to reducing
the spread of HIV. Reducing the practice of unprotected intercourse among
women at risk for HIV and other STIs is a public health priority. As we have
argued, this is a social priority as well as a medical issue.
During our fieldwork, we noticed that all children under 9 years old who were
living with HIV/AIDS were infected through mother-child transmission. This is
not necessary, as medical developments have been found that are effective in
preventing such transmission. The emergence of HIV/AIDS in children can be
attributed to:
1. infected pregnant women not receiving the necessary medical treatment; and
2. the lack of knowledge related to HIV/AIDS and reproductive health among
infected women.
Therefore, preventing mother-child transmission has to do with educating
women at risk for HIV with knowledge about how HIV/AIDS is transmitted,
promoting safer sex and condom usage, and empowering women to better nego-
tiate to protect their sexual rights and reproductive health. It is women who
have suffered the most during this epidemic, due to patriarchal social norms
and practices; it is women who will need to take charge of interrupting the
transmission of this disease.
During the fieldwork, 12 PLWHA reported that their spouses and children
had not been examined, although they were at risk of contracting HIV/AIDS.
Many people chose avoidance because of their fear of stigma and their ignorance
about the disease. In the long term, persuading people at risk of HIV/AIDS to
have examinations as early as possible directly benefits those people, as well
as their families and communities. This responsibility should be on the public
health education agenda and the target of the public health campaign should
be women.
Moreover, we realized that it is not enough to ask women to change individual
behaviors to solve this social problem (for example, demanding that their partners
wear condoms), since the study found that the feminization of HIV/AIDS and of
poverty in HIV/AIDS families are deeply associated with gender oppression and
144 / WANG ET AL.

hierarchies of sexual power. Therefore, it is also urgent that interventions be

designed to address the social and economic inequalities that limit a person’s
ability to make healthy decisions, rather than to try to change the knowledge,
attitudes, and beliefs of the individual. We know that this is not a complex,
long-term project, but one that requires a sustained social commitment. As Cunha
(2007) points out, HIV/AIDS is a social issue and, as such, solutions are needed
at multiple levels, including those at which long-term plans are formulated to
reverse economic and social inequalities.

AUTHORS’ BIOGRAPHIES

Xiying Wang is an Assistant Professor in the School of Social Development and

Public Policy at the Beijing Normal University. She received her PhD from the
Department of Social Work and Social Administration at the University of Hong
Kong. Her research and teaching interests include Chinese women’s studies, gender
politics and human sexuality, qualitative research methods, violence against
women, HIV/AIDS and public health, and post-disaster community development.
email: xiyingw@gmail.com
Xiulan Zhang obtained her PhD in social welfare from the University of
California at Berkeley, in the United States. She is a Professor and Dean of the
School of Social Development and Public Policy, Beijing Normal University. Her
expertise includes behavioral health and costs of illness, social assistance, health
insurance and health policy, social protection, and child welfare. email:
zhang99@bnu.edu.edu.cn
Yuebin Xu, Professor at the School of Social Development and Public Policy,
Beijing Normal University. He obtained his PhD degree from the Department
of Social Work and Social Administration, at the University of Hong Kong.
Before joining Beijing Normal University, he worked at the Civil Affair
College of the Ministry of Civil Affairs as head of the Department of
Social Administration and editor-in-chief of The Journal of Social Welfare.
Xu Yuebin’s major research interest includes social protection, social
services management, and community development. He teaches social security
theory and practice. email: xuyebin@bnu.edu.cn
Yurong Zhang is a research fellow in the School of Social Development and
Public Policy at the Beijing Normal University. She received her PhD degree in
social policy from Beijing Normal University in 2008. Her main research fields
include social policy and rural AIDS problem. email: yurongbnu@gmail.com

ACKNOWLEDGMENTS

The authors express their appreciation to the HIV/AIDS affected people who
participated in this study, and wish to thank Prof. Joshua Miller, from School of
 WOMEN, POVERTY, AND HIV/AIDS IN RURAL CHINA / 145

Social Work at Smith College, for his friendship, encouragement, and comments,
which made this study possible.

REFERENCES
Bossen, L. (2002). Chinese women and rural development: Sixty years of change in Lu
Village, Yunnan. Lanham, MD: Rowan & Littlefield Publishers, Inc.
Cunha, M. (2007). South African politics, inequalities, and HIV/AIDS : Applications for
public health education. Journal of Developing Societies, 23(1-2), 207-219.
Erni, J. N. (2006). Epidemic imaginary: Performing global figurations of “Third World
AIDS.” Space and Culture, 9(4), 429-452.
Fei, X., & Zhang, Z. (2006). Earthbound China (Yunnan San Chun). Beijing: Social
Science Academic Press.
Harvey, S. M., Beckman, L. J., Gerend, M. A., Bird, S. T., Posner, S., Huszti, H. C.,
et al. (2006). A conceptual model of women’s condom use intentions: Integrating
intrapersonal and relationship factors. AIDS Care, 18(7), 698-709.
Hu, Y. (2006). Power, right, and social justice: Gender and HIV/AIDS under the
global perspective. Paper presented at the International Conference on Health and
Development.
Jacka, T. (2006). Rural women in urban China: Gender, migration, and social change.
Armonk, NY: M. E. Sharpe.
Jin, J., Tang, L., Zhao, H., & Lu, Y. (2004). HIV/AIDS and poverty relief work:
Case study of Henan. In W. Jin (Ed.), AIDS in China (pp. 225-241). Beijing:
IPHCC.
Li, L., Sun, S., Wu, Z., Wu, S., Lin, C., & Yan, Z. (2007). Disclosure of HIV status is a
family matter: Field notes from China. Journal of Family Psychology, 21(2), 307-314.
Li, X., & Tang, L. (2005). The study on AIDS and poverty. China Rural Area Observation,
3, 63-71.
Lin, K., McElmurry, J. B., & Christiansen, C. (2007). Women and HIV/AIDS in China:
Gender and vulnerability. Health Care for Women International, 28, 680-699.
Ministry of Health. (2004). The report on HIV/AIDS knowledge, attitude, and behavior
among Chinese citizens. Retrieved February 22, 2010, from http://www.aizhi.net
Patna, J., & Rifkin, S. B. (2007). Equity, empowerment and choice: From theory to
practice in public health. Journal of Health Psychology, 12(3), 517-530.
Scott-Sheldon, L. A. J., Marsh, K. L., Johnson, B. T., & Glasford, D. E. (2006). Condoms +
pleasure = safer sex? A missing addend in the safer sex message. AIDS Care, 18(7),
750-754.
State Council AIDS Working Committee Office & UNAIDS. (2004). The assessment
report on prevention and treatment of HIV/AIDS in China. Available at http://www.
unaids.org.cn/en/index/
State Council AIDS Working Committee Office & UNAIDS. (2007). Report on China
HIV/AIDS prevention and control assessment. Available at http://www.unaids.org.
cn/en/index/
UNAIDS & WHO. (2006). 2006: The global report on HIV/AIDS. Available at http://www.
unaids.org/en/KnowledgeCentre/HIVData/Epidemiology/epiworkinggrp.asp
Wang, Y., & Ci, Q. (2005). Gender analysis of theoretical hypothesis in urban poverty-
related mainstream survey method. In L. Tan, B. Liu, X. Jiang, & R. Nin (Eds.),
146 / WANG ET AL.

Review on the Chinese women’s studies in recent 10 years: Response to the Beijing
platform for action (pp. 30-48). Beijing: Social Science Academic Press.
Wei, H., & Hui, D. (2005). Education to raise awareness of reproductive health: An
important variable in poverty alleviation of women in poor areas—A case study of the
rural areas in central Gansu province. In L. Tan, B. Liu, X. Jiang, & R. Nin (Eds.),
Review on the Chinese women’s studies in recent 10 years: Response to the Beijing
platform for action. Beijing: Social Science Academic Press.
Yang, H., Li, X., Stanton, B., Fang, X., Lin, D., & Naar-King, S. (2006). HIV-related
knowledge, stigma, and willingness to disclose: A mediation analysis. AIDS Care,
18(7), 717-724.
Zhou, R. Y. (2008). Endangered womanhood: Women’s experience with HIV/AIDS in
China, Qualitative Health Research, 18(8), 1115-1126.

Direct reprint requests to:

Xiying Wang
Room 507, Main Building
School of Social Policy and Public Policy
Beijing Normal University
No. 19 Xinjiekouwai Street, Haidian District
Beijing, China, 100875
e-mail: xiyingw@gmail.com