Implication of AIDS crisis in China and its solution

Cynthia Li, Project Syndicate

It is rare for a foreign doctor to get to China's rural areas, where its AIDS epidemic was born and takes a horrible toll. But recently, two nurses and I ventured into a poor farming area, Nizui in Hubei Province, as part of a Medecins Sans Frontihres (MSF) team to visit the Liu family and evaluate their seven-month-old baby. The child was the size of a two month old, but his eyes held the gaze of an 80-year-old man long acquainted with extreme suffering. The baby was dying of AIDS. His parents, aunts, and uncles were also HIV-positive.

The Liu family is one of thousands of poor farming families in China's interior who contracted HIV through contaminated blood donations during the 1990's, when under-regulated for-profit blood banking companies reused needles and transferred blood from infected donors to clean donors after extracting the plasma.

The Chinese Health Ministry recently put the total number of HIV/AIDS cases at 840,000, although most experts believe that the true number is much higher. Some believe that by 2010, the number of infected Chinese may reach 10 million.

After years of taking a passive, low-profile approach to the epidemic, health officials have stepped up their anti-HIV campaign. Since 80 percent of HIV/AIDS patients reside in the countryside, greater access to health care in these areas has become a priority. This past July, during the highly publicized 15th International AIDS Conference in Bangkok, Premier Wen Jiabao declared all-out war against the burgeoning epidemic. Earlier this year, the government promised blood-products screening, free voluntary HIV testing, and free medicine for the poor.

This new anti-HIV/AIDS campaign, which the international community has lauded, is more open and proactive than before. But it must still operate in the context of a closed society, where government control over the media limits the flow of information necessary to deal with any public health epidemic. Moreover, it is unclear how care will be delivered to the rural front lines, where the old system of clinics based in Peoples' Communes collapsed with the de-collectivization of agriculture.

To be effective, clinics in areas where HIV/AIDS is prevalent must provide patients with the same standard of care that is offered for other health conditions. Unfortunately, the door to such access remains largely closed, partly because China was initially reluctant to allow overseas groups into their hinterlands to assist. Nonetheless, local and foreign NGO's are now starting to play a role in filling the gap between government policies and front-line healthcare delivery. In May 2003, MSF was authorized to set up an HIV/AIDS clinic in Xiangfan, Hubei Province.

On my recent visit, I met Du, a thin-framed, HIV-positive farmer who lost his wife to AIDS last year and was desperate to prevent his infected seven-year-old son from meeting the same fate. He had been taking the boy all over China by train, bus, and truck in search of help. Last month alone, they visited five large cities without success. The chance that Du, and those like him, will find help in China is slim; at present, most clinics and hospitals are not adequately prepared to treat HIV-infected patients.

Treatment is extremely limited where it is available. For example, Xiangfan's Infectious Diseases Hospital is the prefecture's only health facility where HIV/AIDS patients can be admitted. On paper, the hospital appears well staffed and adequately equipped, but on my rounds there, I found the halls and wards deserted and barren. Few therapeutic and diagnostic options were available. Even a basic test like a CAT scan would require transport to another regional hospital.

But under-equipped hospitals may not be the greatest obstacle to controlling China's AIDS crisis. Equally harmful are the government's sensitivity to its own policy failures and the stigma attached to a disease that is often sexually transmitted. Indeed, information is so limited and the stigma so strong that ordinary people -- and sometimes medical personnel -- often ostracize AIDS patients.

Patients who do receive care are often treated with substandard, even harmful, medicine. According to the International Federation of Pharmaceutical Manufacturers Associations, patients in China can have a 40-50 percent chance of being sold fake over-the-counter remedies and an even higher chance of being sold fake prescription drugs. Some of these counterfeit products contain toxic ingredients.

Foreign NGOs such as MSF insist on using medications that are up to World Health Organization standards, but the Chinese government insists that such restrictive measures are excessive. Although MSF uses its own drug supply, Chinese patients still often buy medicine with unknown ingredients and efficacy on the street.

Safety regulations must, at a minimum, be applied to the prescription of the anti-retroviral medications that fight HIV, because such drugs are extremely sensitive to dosage changes and interactions with other medicines. Improper use of these medicines fosters HIV resistance and provides little therapeutic value for patients.

There is no quick-fix solution to ending China's AIDS crisis. Officials there must focus not only on developing a pragmatic, realistic healthcare infrastructure in rural areas, but also on bringing about greater openness in China's media in order to spread life-saving public information.

Like all epidemics, HIV/AIDS in China is a public health crisis that can only be solved with the mass dissemination of accurate information. Transforming promises and policies into patient rights, awareness, and effective health care will undoubtedly take time, especially for a country as massive and lacking in transparency as China. For the hundreds of thousands of HIV sufferers, this is likely to be more time than they have left.

Cynthia Li, M.D., a physician previously with Kaiser Permanente's HIV group in San Francisco, California, worked as a volunteer doctor with Medecins Sans Frontihres in China.