LONDON. A court in the poor Chinese province of Henan has ordered a local health authority — the Xinye County Health Bureau — to pay 380,000 Renminbi (RMB) (around £30,000 or US$45,000) to the family of a six-year-old child who was infected with HIV through a blood transfusion after a playground injury, according to a report in the 7 August
The story is not likely to be isolated, for it has brought to the surface estimates that there may be 2–4 million people in China who have been unknowingly infected with HIV through ill-managed, private blood banks — more than quadrupling previous calculations of the numbers of HIV-positive persons in China. For example, UNAIDS in its 2000 report (published in June) used a figure of only 500,000 HIV-positive people.
But the potential financial liability from blood-bank transmission — running into hundreds of billions of dollars — is crippling research into this terrifying problem, so the exact numbers and locations of people infected, and whether this transmission route has been slowed or stopped by government intervention against the rogue banks, remain unknown.
"It's a very, very political issue," said Dr Shenghun Lai of the Department of Epidemiology at Johns Hopkins School of Public Health in the USA, who has recently been to China to plan research projects in HIV transmission.
"It's hard to approach [the blood bank problem] even as a researcher," Dr Lai told BioMed Central. "It's not the Ministry of Public Health — they say you can go where you like and get whatever information you want. The trouble comes at the lowest, county level …" [China has a central government, beneath that provincial governments, beneath them city governments and then county administrations.] Lai himself visited Henan, where the six-year-old was infected, but was able to collect little data. "It's very hard, especially as a US citizen, they could accuse me of being provocative. I can't do research on that anymore." Instead Lai will focus on transmission through needle-sharing in intravenous drug-use and through sex workers.
As a proportion of the 1.2 billion population of China the number of HIV-positive persons is still small, and up to now these people have been thought to be mainly users of intravenous drugs on heroin trade routes. But rural, private blood banks, where donors are paid for their blood and a few donors give blood professionally, may have broken the barrier and taken HIV into the general population. Such blood banks continue to operate, even though payment for blood donations is now forbidden.
Other sexually transmitted diseases, which are thought to assist HIV transmission, are also rising rapidly in China, perhaps reflecting changes in behaviour. According to the National STD Centre in Nanjing, STD incidence in China grew from 233 cases per 100,000 persons in 1998 to 325 in 1999 — an increase of 39%. Meanwhile, according to UNAIDS, only half Chinese prostitutes say they always or sometimes use a condom.
Estimates of the real number of HIV cases in China vary widely. According to the 21 August edition of the official newspaper
But according to the US embassy in Beijing, internally several national Chinese government agencies are using a figure of 4 million people currently infected. The range of estimates is thus 0.6–4 million. If the latter, internal government figure is correct, the projection for 2010 — assuming the same rate of growth that gave the CAPM prediction of 10 million — must be 33 million cases, comparable to the UNAIDS 1999 total world figure of 34.3 million.
There are two main reasons for the deep uncertainty in these numbers. First, the impact of blood bank transmission is poorly known and research is politically difficult; and second, much of the transmission is likely to be among the 80–120 million 'floating population' — unregistered, uneducated and little-studied migrants from the rural areas, who flocked towards the cities in the 1980s. This created a great new volatile underclass, poorly connected with the health system, and seeking to earn money however possible, including by prostitution and by the sale of their blood — even though this is now illegal.
Nationwide blood collection began to be encouraged in 1988, in order to reduce the risk of HIV entering China through blood imports. But HIV entered anyway by several routes, the most efficient being through heroin injectors using shared equipment along overland heroin trafficking routes originating in Myanmar and Laos.
Then at the end of 1994 there was a limited outbreak of HIV among paid blood donors. A survey of Hepatitis C infections in Hebei Province demonstrated that virus transmission could occur during blood donation, and so raised serious doubts about the quality of the blood banks. Among non-donators, Hepatitis C rates were under 2%, but among blood plasma donors the figure reached 67%, with much lower figures in whole-blood donors. The conclusion was that the method of collection of blood plasma, which involves returning red blood cells to the donor after separation of the blood, was responsible for the transmission of Hepatitis C, and that a similar effect was taking place with HIV.
The government responded with measures to reorganize the blood market but it freely admits that resources have been inadequate, the quality of local HIV testing has been weak and illegal collection of blood and plasma has continued uncontrolled — at least outside the cities. Although payment for blood donations is now forbidden, in 1997 there were about three million paid donors, most living in poor provinces of central and southern China such as Henan, Hebei, Anhui, Shanxi and Guizhou.
There is evidence that heterosexual HIV epidemics have started in a number of sites in Yunnan: in Ruili 6% and in Lijiang 11% of male STD patients who are not drug users are HIV positive. Sentinel testing for HIV in pregnant women receiving antenatal care is limited, but in Yunnan the rate was estimated to be 1% in 1998 and 1.6% in 1999, with similar figures for Xinjiang, according to UNAIDS.
The next two years will tell, Beijing AIDS experts say, whether China will manage to get a grip on this potential epidemic.