Who is at risk?
The inability of China's public health surveillance system to determine accurately the number of HIV infections in the general population makes it difficult to assess those at risk. At the end of 2002, there were only 158 national HIV/AIDS surveillance centers in operation—many affiliated with detoxification centers for drug users and commercial sex worker re-education centers run by the Ministry of Public Security. The Ministry of Health believes that more than 10,000 sites would be necessary to assess the full magnitude of the epidemic.

Other emerging infectious diseases provide important indications about HIV's potential to spread throughout China. Hepatitis B and C currently infect more than 200 million people in China and are analogous to HIV/AIDS in some ways because many people who become infected unknowingly carry the virus for years before manifesting symptoms. In the meantime they infect others through sexual contact, blood product donation, and improper reuse of medical equipment. The extent of the hepatitis epidemic and the rapid increase of sexually transmitted infections in both urban and rural areas since the early 1980s indicate that HIV/AIDS will likely spread to the general population. There is currently a false feeling of security among many Chinese people who believe that HIV/AIDS is a "foreigner's" disease that will only affect marginal populations, making prevention and education an important task for companies seeking to protect their employees and communities.

What are the costs of HIV/AIDS to businesses?
When HIV/AIDS enters the workforce in appreciable numbers, businesses face significant added costs and reduced revenues. HIV/AIDS affects businesses' competitiveness in three ways. Primary costs, such as labor, increase. When sick employees miss work, worker productivity declines and employee turnover, healthcare expenses, and social burdens such as insurance premiums and death benefits increase. Secondary costs, such as low morale and strained relations between workers and management, often occur. Businesses also experience tertiary costs such as damage to corporate reputations and the decline of product markets and investor interest.

Primary costs
The well-documented increase in labor costs brought on by the HIV/AIDS epidemic in Africa and Southeast Asia indicate what companies operating in China may face in the future. Many people who contract HIV are unaware that they are ill and work for several years before their health begins to decline. The impact of HIV/AIDS first hits businesses when a worker's absenteeism increases and may be particularly severe for companies that employ skilled workers. A study in Beijing conducted between 1994 and 1999 found that HIV-infected people spent an average of 89.6 days per year in the hospital and made an additional 2.7 outpatient visits per year. Because of the highly personal nature of Chinese business relationships, moreover, the absence of key workers may amplify the impact of HIV/AIDS. Compounding matters, healthy employees often contribute to worker absenteeism rates when they take time off to care for HIV-infected family members. When workers are absent, remaining employees take on extra work, which results in higher overtime costs and workplace stress. Workers and their families may also demand death benefits, funeral expenses, and bereavement leave, further raising the costs of business for employers.

These costs—in terms of managers' time, staff disruption, training, and productivity—could have a major impact on companies in China. Hiring a new employee can cost several months' salary to three times an annual salary depending on the position and industry. Regardless of whether the person being replaced is skilled or unskilled, experienced workers are more productive and generate more profits.

Secondary costs
It is difficult, yet necessary, to measure the secondary costs of HIV/AIDS. Employees and employers typically are unaware of any given worker's HIV status. A rising number of illnesses within a company may not initially be attributed to HIV/AIDS since few Chinese doctors are qualified to diagnose it. Because HIV depresses the immune system, patients may die from opportunistic infections, including tuberculosis, which may be named the official cause of death. As the incidence rate increases within the community and more doctors become aware of HIV/AIDS symptoms, the diagnosis will be made more often—affecting society more openly. Once the incidence of HIV/AIDS rises, employee morale may plummet and industrial accidents may occur more frequently because of sickness, stress, depression, and even fatalism—further reducing productivity.

Worker-employer relations can suffer once HIV/AIDS permeates a workplace. The primary conflict arises when expensive, lifesaving treatments lie beyond the financial reach of employees and are not covered by insurance plans or employee healthcare systems. Currently, antiretroviral treatment, known as the "AIDS Cocktail" (aizibing jiweijiu) is available in Beijing and Shanghai using imported drugs. The cost, prohibitive to most patients, is around $5,000 per year. Several Chinese pharmaceutical companies are rushing generic versions to market, hoping to lower the price to a more manageable $1,200 per year. Companies will inevitably face difficult decisions about whether to expand benefits to include life-prolonging treatments for employees and their dependents.

Tertiary costs
Companies in China face significant costs and risks from HIV/AIDS in the wider community. The most significant risk is to a company's brands and image. If a company does not provide life-prolonging treatments to its infected employees, it can be branded insensitive or ruthless and risks consumer boycotts. Consumer-product companies are particularly vulnerable to popular perceptions of their brands. Poorly planned HIV/AIDS policies, or an absence of such policies altogether, can thus have negative effects on the company. A company that is severely affected by HIV/AIDS can suffer from a lack of investor confidence and may lose access to capital.

Perhaps the greatest external cost of HIV/AIDS to a company is the impact of a decline in the greater economy. HIV/AIDS primarily affects workers in the most productive periods of their lives. Their incapacitation can reduce family incomes, and payment for treatment can eliminate their savings. The result is reduced spending and demand for goods and services, particularly for non-essential items and services. Writ large, this situation can spell macroeconomic decline, not only in areas where HIV/AIDS is prevalent, but across the country or region. Thailand is a case in point. A Thai government study in 2000 estimated that the direct and indirect cost of HIV/AIDS to the nation was $1.2 billion. Additional estimates suggested that the Thai HIV/AIDS epidemic could be costing the Japanese economy between 1 and 2 percent of its annual GNP through losses in trade and potential markets. As markets shrink and labor costs increase, profitability becomes harder to attain.

	Learning from SARS
	Severe acute respiratory syndrome (SARS) has raised troubling questions for Chinese citizens—including corporate citizens —about the nature of risk in China and the government's ability to respond to rapidly developing crises. The PRC government's response to SARS has mirrored the government's reaction to HIV/AIDS. The government initially reacted with misinformation and denial, then, after heavy international pressure, admitted the problem and eventually cooperated with foreign partners, though with some reluctance and suspicion at the outset. Though SARS has garnered signifi- cant political attention and has mobilized society, China's capacity to cope with more slowly spreading, more lethal, diseases is by no means assured. The SARS outbreak revealed shortcomings in China's medical and political systems. Medically, SARS presented a huge challenge to the entire healthcare system. At the clinical level, doctors and nurses were infected in disproportionate numbers, hospitals quickly became overwhelmed, and the army stepped in to provide medical staff for civilian hospitals. Public health oversight capacity was also strained	by SARS, as virtually all infectious disease specialists in the government were unable to continue their daily work on other diseases. Politically, SARS exposed the PRC government's initial inability to address rapidly developing crises. The outbreak underlined Beijing's communication difficulties with provincial authorities. Poor communication between the Ministry of Health and Beijing city health authorities also showed that even in the capital, lower-level officials do not always report in a timely and accurate fashion. The subsequent sackings and reprimands of close to 1,000 provincial- and local-level officials for inadequate handling of the SARS epidemic illustrates the central government's frustration with officials who do not follow its commands quickly enough; the need to punish some officials in order to motivate others; and careful public relations. The government's obstruction of the World Health Organization and United Nations public health teams exposed a continuing distrust of outsiders, which does not bode well for more openness in the future. Though the political establishment eventually mobilized	society and improved communication between the provinces and the center, it is unclear at this point if these developments will translate into more effective responses to other dynamic crises in the future. SARS has done what other infectious diseases in China have thus far failed to do: capture the attention of the top leadership and the international community. Fortunately, it has infected a relatively small number of people, caused fewer deaths, and as this article goes to press, is on the decline. The economic impact has been sharp, but should be brief. Preventive measures, including screening and quarantine, have proven effective. Unlike SARS, however, HIV/AIDS is a terminal illness in all cases, infects the young and productive at high rates, and will have a long-term economic impact. Though some observers hope that SARS will engender a new sense of openness, it is still unclear that the PRC government has made such a commitment or that it will apply its experience in dealing with SARS to other infectious diseases. —Bates Gill and Andrew Thompson

How businesses can mitigate the impact of HIV/AIDS
The Chinese workplace generally influences employees' personal lives, social values, and behavior. Though the work unit (danwei) system has removed itself from many aspects of workers' lives, all companies in China still influence workers' attitudes and are in a unique position to provide public health education and a healthy working environment. Preventing the spread of HIV and hepatitis within a company's workforce is both economically and humanely preferable to absorbing the costs of replacing workers lost to AIDS or other diseases, or to treating infected workers.

Though many managers and experts are concerned about the impact of HIV/AIDS on businesses in China, few companies have taken concrete steps to protect themselves from the economic costs of blood-borne diseases. A 2002 survey of businesses in Beijing conducted by the Futures Group Europe found that only 8 percent had an established HIV/AIDS policy, while 26 percent had policies concerning hepatitis, and 9 percent had policies on sexually transmitted diseases (STDs). Only 3 percent of the companies reported that they had policies and programs specifically designed to address HIV/AIDS in China.

To mitigate the future impact of HIV/AIDS, hepatitis, and other blood-borne diseases, a company should establish an HIV/AIDS, hepatitis, and STD policy and disseminate it to all employees; provide preventive education to its workforce and families; involve the wider community in education programs that, among other goals, attempt to reduce the stigma of such diseases; extend prevention messages and incentives to vendors and suppliers who also undertake prevention programs; and make preparations for the care and support of workers and their families.

Developing an HIV/AIDS policy for the workplace
The issue of HIV/AIDS is socially sensitive in China because of the widely held misperception that the disease only afflicts marginalized groups, such as drug users, sex workers, and men who have sex with men. Most Chinese are also reluctant to discuss sexual topics, particularly when illegal or "immoral" activities are the focus. Others believe that HIV/AIDS is a personal issue similar to hygiene that companies do not need to address.

An HIV/AIDS, hepatitis, and STD policy should state the company's position and practices for preventing the transmission of these diseases and for handling infection among employees. The policy should comply with local and national laws, establish behavioral guidelines for all employees, and provide resources both within the company and outside it for assistance and counseling. The policy should specify the benefits and medical services that are included in the company's healthcare program and ensure that confidentiality and privacy are guaranteed. Ideally, employees will be involved in creating the policy so that they have a stake in the results, are receptive to future education programs, and can become a resource for other employees. An employee-designed policy more effectively influences attitudes and exerts peer pressure on the entire workforce. The formation of the workplace policy is the first step toward reducing the stigma of the disease, which should be a goal of any policy.

Organizations have used innovative methods to break down the stigma. Some companies have detailed expected behavior of all staff toward coworkers who are infected or who have infected family members. By including hepatitis and other diseases that have similar epidemiological characteristics as HIV/AIDS in their policy, companies have shown employees the impact and transmission routes of these similar diseases, demonstrated that these diseases are widespread, and (because of the potential for clinical transmission through illegally reused medical devices) emphasized that all employees and their family members may be at risk of contracting these diseases, regardless of their marital status.

As part of the policymaking process, companies should review existing policies and consider whether they could contribute to dangerous practices. For example, a manager in a Beijing company expressed concern that his company's policy of providing a certain number of paid "sick days" to employees, combined with a reimbursement policy for medical expenses, led employees to view these policies as part of a benefit package that needed to be used or lost. The manager was aware that many employees took days off, even when they were not ill, to use up their sick days and visit the doctor to get vitamin and other "pick-me-up" injections, intravenous drips of herbal medicines, and possibly even blood products. Because of the frequent reuse of needles and catheters in unregulated facilities in China, the manager was extremely concerned about the possible impact on the company's employees. Companies faced with similar situations need to consider solutions, such as providing workers who do not use up their sick days with bonuses, and reimbursing expenses only from qualified hospitals and clinics.

Developing health education programs for the workplace
After a policy is in place, the next step for a company in China is a health education program for the workplace. The ultimate goal of such an education program should be to keep a company's workforce healthy and productive, thus maximizing productivity while reducing costs from absenteeism, increased healthcare services or insurance premiums, and staff turnover. The health education program should help prevent employees and their dependents from becoming infected with HIV (and other diseases) as well as eliminating the stigma of infected coworkers, as already mentioned. Of course all companies have different workforces and should tailor their programs to suit the age, education level, gender, and behavioral risk factors of their workers.

No one program will suit the needs of all companies, but successful programs share common elements. Education programs are most effective when delivered by peers and when workers are involved in program development. Programs need to teach the basic means through which HIV, hepatitis, syphilis, and other STDs are spread, along with preventive measures, such as condom use. Again, employees should be made aware of the danger of reused needles and syringes in clinical settings—and be empowered to demand clean, single-use needles and syringes, and screened blood products. Employees must also learn how these diseases are not spread—programs should emphasize that casual contact in the workplace presents no risk of HIV infection.

Good programs provide a forum for discussing how all employees, including senior management, should treat infected coworkers and how the company's policy affects everyone. Programs should discuss occupational hazards, how to handle accidents at work, training for onsite medical staff, and basic first aid procedures for all staff. Education programs that conduct mandatory training in small groups and on company time have high success rates. Perhaps most important, healthcare education programs need to be monitored for effectiveness with follow-up meetings, and companies must solicit feedback from workers to determine employee understanding of the issues.

Training programs should provide resource materials, including pamphlets or printouts with key messages, workplace issues, and company policies. Employees should be encouraged to bring handouts home and educate family members and peers outside the office. The 2002 business survey in Beijing confirmed that 75 percent of companies surveyed would like to provide an HIV/AIDS initiative, particularly if the program is culturally sensitive.

Supporting communities
Companies, as members of the communities in which they operate, have a vested interest in involving the wider community in their education programs, reducing stigma, and extending prevention messages and incentives to vendors and suppliers who also undertake prevention programs. Companies also have a vested financial interest in maintaining the health of the community and ensuring that there is disposable income available for their products or services.

Insurance companies can be valuable resources to help their customers implement programs within their own organizations. The lower the rate of infection, the lower the cost to the insurance company in terms of healthcare payouts. Insurers may also find that support for educational programs enhances their brand by fostering positive public perceptions and attracts new business by providing value-added products. Insurance companies in many countries also provide discounts or credits to companies with effective workplace HIV/AIDS policies. These savings can help a company justify the cost of developing and implementing a healthcare program. In 1999, American International Assurance, Thailand, a subsidiary of American International Group, Inc., started an evaluation and accreditation program to provide premium credits to companies implementing HIV/AIDS policies and education programs in the workplace. By combining HIV, hepatitis, and other similar diseases into these programs, insurance companies in China stand to generate even greater savings.

Businesses outside of the insurance industry also have opportunities to provide incentives to suppliers to implement healthcare policies and education programs. Manufacturers face higher costs if their vendors' costs rise, so promoting healthy workplace policies and programs within their supplier networks makes good business sense. Many manufacturers already require their original equipment manufacturer and service suppliers to attain International Organization for Standardization certifications or require vendors' business practices to mesh with theirs. By sharing existing education programs and policies and using outside resources, companies can reduce the cost of designing and implementing their own policies and programs.

Providing care, support, and treatment
Not surprisingly, the 2002 corporate survey found that less than 10 percent of FIEs in Beijing had seen any impact from HIV/AIDS in their workforce. Little data exists about the impact on businesses throughout China, but companies should factor in the anticipated costs and scope of their programs when designing their care policies. The first step is to review local and national laws to determine the legal implications for the company. Second, companies should survey healthcare capacities—both within the company if applicable, and in the wider community—to ascertain high-quality care providers. If local clinics are reusing medical equipment, then workers might be at risk, and appropriate actions should be taken by the company to isolate those facilities and encourage staff to seek treatment elsewhere. Identifying additional community resources, including local health authorities, nongovernmental organizations, and insurance companies are key to assembling the components of a comprehensive care plan.

Once policies and educational programs are under way, companies can consider undertaking a testing program that will establish the baseline for treatment needs. Of course, no company should establish a compulsory testing program, and any voluntary program should ensure that employees' status be kept confidential. Testing for STDs enables workers to get treatments for curable diseases, increasing their productivity. STDs contribute to the spread of HIV through inflammation, ulcers, and more infected white blood cells—which facilitate the transmission of HIV during intercourse. Treating STDs is an effective means of preventing HIV, and diagnosing a curable STD can serve as a wake-up call for employees who do not consider themselves at risk of contracting HIV. Testing for hepatitis can also alert workers to potential liver problems and enable them to begin treatment regimens that will enhance their quality of life and make them better, more productive employees. HIV testing can be difficult to implement, particularly if employees do not wish their employers to know their HIV status and worry that they will face discrimination.

Companies also must consider other ethical issues with HIV screening policies, both for new hires and the existing workforce. For example, poorly designed HIV screening may be incompatible with prevention and empowerment programs.