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E D I T O R I A L C O M M E N TA R Y
Antiretroviral Therapy for Former Plasma Donors in China:
Saving Lives When HIV Prevention Fails
Han-Zhu Qian1,2,4 and Sten H. Vermund1,3,4
1
Institute for Global Health, 2Vanderbilt Epidemiology Center, and Departments of 3Pediatrics and 4Medicine, Vanderbilt University School of Medicine, Nashville,
Tennessee
(See the article by Zhang et al. on pages 825–33)
The spread of HIV and other bloodborne
infections in rural communities in eastcentral China in the late 1980s and early
1990s was a tragic public health event. This
occurred at a time of great transition. A
market-oriented economy was emerging
across the country, and the communebased rural health care system was collapsing. From the 1950s through the
1970s, China had established a 3-tiered
health care infrastructure, including village barefoot doctors, township health
care centers and county hospitals, and a
low-cost Cooperative Medical System that
provided basic health insurance [1]. This
primary care infrastructure and basic insurance scheme served rural residents efficiently during a time that 180% of all
Chinese persons lived in rural areas (compared with 50%–60% in 2008). The infant
mortality rate decreased from ∼200 of
1000 live births in 1949 to 47 of 1000 live
births in 1975, and life expectancy increased from 35 years in 1949 to 65 years
in 1975 [2]. China’s gross national income
per capita in 1975 was only $230, suggesting that the improvement in health in-
Received 16 May 2008; accepted 19 May 2008;
electronically published 8 August 2008.
Reprints or correspondence: Dr. Sten H. Vermund,
Vanderbilt Institute for Global Health, 2525 West End Ave.,
Ste. 750, Nashville, TN 37203–1738 (sten.vermund
@vanderbilt.edu).
Clinical Infectious Diseases 2008; 47:834–6
2008 by the Infectious Diseases Society of America. All
rights reserved.
1058-4838/2008/4706-0017$15.00
DOI: 10.1086/590940
dices was an extraordinary public health
and primary care achievement [3].
China began to move away from central
planning toward a market economy in
1979. China’s agricultural reform substituted a “Household Responsibility System” in place of the deteriorating 3-tiered
medical system and the almost defunct
Cooperative Medical System [1]. Chinese
persons living in rural areas have seen
many changes. “Barefoot doctors” funded
by the communes used to provide basic
primary care, but they have been replaced
by small health-related entrepreneurs, including fee-for-service medicine. Government services, such as hospitals, now
charge far higher fees for their services
than before. A new emphasis is placed on
the training and placement of “village doctors,” who have ∼3 years of primary care
training and who charge for their services.
The public health system has also
changed. Modern China relies less on
community mobilization for public health
achievement, which was the case with the
successful campaigns devoted to such
problems as malaria and schistosomiasis
during past decades. In place of these
commune-based volunteer programs,
government public health programs now
seek to involve community-based organizations, typically not as volunteers but
as paid partners.
In this context, illegal commercial blood
collection activities emerged in poorer rural communities in the late 1980s and early
834 • CID 2008:47 (15 September) • EDITORIAL COMMENTARY
1990s, often abetted by corrupt local leaders or health officials. Voluntary blood donation does not meet the demands of the
medical system in China. Blood is seen as
a vital fluid in Chinese society. Donations
are typically made in 200–250 mL volumes, rather than the 450–500 mL volumes obtained in American or European
donations. In China, fewer people donate
blood and they donate in lower volumes
than in many other nations. In this environment, unscrupulous businessmen offered money for blood in illegal mobile
rural blood donation schemes. These businessmen used plasmaphoresis to harvest
plasma and reinfuse pooled RBCs of the
same blood type, such that persons could
donate again in a short time (typically
within 1–4 weeks) without becoming anemic. Thus, farmers and their spouses donated blood repeatedly in short periods of
time to supplement their very low incomes, until the itinerant blood procurers
moved elsewhere.
Mixing blood for reinfusion guarantees
the transmission of bloodborne pathogens, of course, given that a single infected
donor can infect dozens of other donors.
The consequent epidemics of HIV and
hepatitis C virus are well documented [4–
8]. The spread of hepatitis B in this environment has been less well studied, but
1 study suggested that it may not have
been spread as extensively, for unknown
reasons [4]. Chinese officials suppressed
this destructive and illegal business in the
early 1990s, but only after much damage
was done. An estimated 57,000 former
blood and plasma donors have been infected with HIV in Henan, Anhui, Hubei,
and Shanxi provinces [9].
More than a decade has passed since
the apex in activity of these grotesque illegal plasma collection activities. Many infected former plasma donors have advanced HIV disease and need access to
health care that is beyond their economic
means. To respond to this need, the Chinese government started the China Cares
program in 2003, with the slogan “Four
Frees and One Care.” The program offers
free HIV testing, free antiretroviral treatment (ART), free services for preventing
mother-to-child transmission, free schooling for those who are orphans because of
AIDS, and care and economic assistance
to the families of people living with HIV/
AIDS. This nationwide program gives special attention to rural communities with
a large number of HIV-infected former
plasma donors.
In this issue of Clinical Infectious Diseases, investigators from the Chinese Center for Disease Control and Prevention
and the US National Institutes of Health
report the impact of the national program
that provides free ART on mortality in a
subset of 4093 Chinese former plasma donors [10]. A thoughtful analysis demonstrates that the hazard of mortality among
those not receiving ART is 2.8-fold greater
than that among persons receiving ART.
The authors correctly recognize the potential bias of assessing clinical effectiveness outside the context of a clinical trial.
They demonstrate that the sickest persons
were most likely to receive ART, which
suggests that their findings might be a conservative estimate of the benefits of ART
for rural former plasma donors infected
with HIV in China.
That the program has reduced mortality
substantially in a very rural setting is an
inspiration for the global push to provide
HIV care in rural areas. In the United
States, millions of life-years have been
saved with antiretroviral drugs since 1989
[11–12]. The policy for universal access to
treatment in Brazil yielded a 40%–70%
reduction in mortality, a 60% reduction
in morbidity, and an 85% reduction in
hospitalization from 1997 to 2003 [13]. In
sub-Saharan Africa, where 68% of the
world’s HIV-infected adults and 90% of
the infected children reside, the number
of infected people with access to ART increased from 100,000 to 11,000,000 from
2003 to 2006 [14]. In settings as diverse
as Haiti and Zambia, ART delivery programs are saving lives on a large scale,
although to date, published data from
large-scale programs are primarily from
urban centers [15, 16]. China’s success in
overcoming constraints in rural care infrastructures to provide life-saving care
and treatment to infected persons demonstrates the feasibility of rural HIV care
programs [10].
China’s AIDS epidemic and ART program have characteristics that suggest special opportunities and challenges. Chinese
farmers and their spouses in the poorer
former plasma-donating communities in
Henan and surrounding provinces typically have low-risk lifestyles; little secondary transmission has been documented
[4]. However, China is a large country, and
secondary transmission is feasible in some
rural venues where high-risk behaviors are
prevalent [17]. Most Chinese persons living with HIV/AIDS reside in rural regions,
including Xinjiang, Guangxi, and Yunnan
provinces, where injection drug use is
driving HIV transmission [9, 18]. An increasing proportion of new HIV/AIDS
case reports in China over time are attributable to sexual transmission [9, 19].
In 2007, the number of reported cases of
HIV infection attributable to sexual contact surpassed the number of cases attributable to the previously dominant route
of infection—injection drug use—for the
first time. Many female sex workers and
men who have sex with men may become
infected with HIV in cities and later serve
as an epidemiological “bridge” to their rural home regions of origin. This is exactly
what occurred in the southeastern United
States; an early wave of rural cases reflected
residents returning home from urban areas after becoming infected, but later cases
were autochthonous [20, 21]. Illegal drug
users, sex workers, and men who have sex
with men face challenges of stigma and
fear of arrest in China, which inhibits their
pursuit of counseling and testing, prevention, and health care services. Although
the need to provide care and treatment in
central China, where former plasma donors reside, is obvious and urgent, there
are many other rural areas where sexual
and drug injection risks continue to be
factors and prevention programs are
inadequate.
More and more infected former plasma
donors will develop symptomatic AIDS in
the next few years, and those currently
receiving ART will live longer than previously untreated patients; the demand for
care will increase. Few rural residents now
have health insurance. The Chinese government has made rural health care reform a top priority. The New Cooperative
Medical Scheme, a government-run voluntary insurance program, was initiated
to insure rural residents against catastrophic health expenses and to protect
them from impoverishment by illness
[22]. The annual premium is 50 yuan
(∼$7); the central and local governments
pay 20 yuan each per person, and the
farmers pay 10 yuan per person. Fifty yuan
represents one-third of a farmer’s estimated health spending in the poorer central and western provinces of China [22].
So far, this new scheme has not taken HIV/
AIDS into consideration; the limited pool
of insurance-derived funding in communities with a large number of patients
with AIDS would deplete the reserves of
the New Cooperative Medical Scheme.
The Chinese government will need to continue expanding the China Cares program
in these areas.
Monitoring drug resistance and increasing drug options for patients infected with
drug-resistant viruses is necessary. A 2005
publication from Henan province indicated that 18%–62% patients who re-
EDITORIAL COMMENTARY • CID 2008:47 (15 September) • 835
ceived treatment for 16 months had developed drug-resistant infection [23].
Improved laboratory capacity, drug procurement systems, and drug quality control systems are needed. Most importantly
for drug-resistance prevention, adherence
programs based on person-to-person assistance, pharmacy-based approaches, and
mnemonic-help systems are vital [24–26].
Fortunately, the rural Chinese health
system network is still functioning well,
although it is economically inaccessible for
too many people. The booming economy
of the past 3 decades has accumulated
wealth at both central and provincial levels. If China maintains its strong political
will to help with HIV care and treatment,
China’s ART-based programs can continue to expand to meet the substantial
and growing need for HIV care and ART.
5.
6.
7.
8.
9.
10.
Acknowledgments
Potential conflicts of interest. H.Z.Q. and
S.H.V.: no conflicts.
11.
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