Editor—Zhang and Ma's editorial paints a somewhat misleading and incomplete picture of the epidemiology of HIV in China.1
Firstly, the numbers of HIV infections need to be seen in terms of percentages. Even if the highest current estimate of 1 million infections nationwide is used, this converts to an overall rate of around 0.07%. The male: female ratio is 4:1 and unlike almost any other country most of the people affected (80%) are residents of rural areas. At present four provinces (out of 31) account for 77% of all cases: Yunnan, Xinjiang, Guanxi, and Guangdong. This is because of the predominance among drug misusers (www.ns.unchina.org/unaids). The breakdown of mode of transmission is given in the table.
Secondly, although we completely agree that drug misusers, commercial sex workers, and to a much lesser extent migrant workers are current drivers of the epidemic, there is an important omission: commercial blood donors.2 The government itself admits that 30 000 to 50 000 plasma donors have become infected through faulty blood collection practices, and many local reports suggest that these figures are a gross underestimate. And this does not consider the sexual partners of the donors and the recipients of infected blood products. Although measures were introduced in 1997-8 to outlaw commercial blood donation, and the scale of the problem has reduced, they have succeeded in driving the practice underground with potentially greater risks to donors. 
Thirdly, Zhang and Ma portray the surveillance system as extensive and efficient. But this is far from the case. One of the reasons that so much about HIV prevalence is speculation is because the surveillance system is totally inadequate. In fact, HIV is rarely tested for outside the official HIV surveillance system. This system targets high risk groups, provides poor guidance about sampling at a local level, and the number of samples tested and the sites themselves vary from year to year, threatening any credibility to detect time trends. There is no true population based surveillance being carried out.
The government has indeed made a strong commitment to prevention. But the general philosophy is still one of eradicating the risk behaviour, rather than educating about risk reduction: so drug misusers are incarcerated and sex workers imprisoned, as Zhang and Ma note. This of course makes it very hard to effectively target prevention measures. This is compounded by the fact that local officials are frequently afraid to admit to an HIV problem in their area and cases go missed and unreported. Greater openness and more tolerance towards HIV sufferers and those in high risk groups are an essential prerequisite for effective control of the epidemic.
Table.
Mode of transmission of HIV in China: official figures
| No of cases | |
|---|---|
| Heterosexual | 407 |
| Homosexual | 12 |
| Intravenous drug misuse | 3460 |
| Blood transfusion | 107 |
| Blood products | 8 |
| Vertical | 10 |
| No detail | 1197 |
| Total | 5201 |
Source: Ministry of Health sentinel surveillance data (www.ns.unchina.org/unaids).
References
- 1.Zhang KL, Ma SJ. Epidemiology of HIV in China. BMJ. 2002;324:803–804. doi: 10.1136/bmj.324.7341.803. . (6 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Wu Z, Rou K, Detels R. Prevalence of HIV infection among former commercial plasma donors in rural eastern China. Health Policy and Planning. 2001;16(1):41–46. doi: 10.1093/heapol/16.1.41. [DOI] [PubMed] [Google Scholar]