Rural Chinese villagers with HIV have high rates of undetected hepatitis C (HCV) infection, and are potentially compromising treatment with antiretroviral drugs, according to a study published in the journal AIDS last month.
In a cross-sectional study done in four villages in Shanxi province, where blood-selling was common practice in the 1990s among farmers needing extra income, a collaborative team of Chinese and American researchers has found that 85% of HIV-infected villagers were co-infected with HCV.
In their report, authors Han-Zhu Qian of the Chinese National Center for AIDS/STD Control and Prevention and Sten Vermund of Vanderbilt University in the United States call on the Chinese government to do more to identify and treat people infected with both HIV and hepatitis C.
“The Chinese government has initiated free ART programs for the infected rural plasma donors since 2003, but these programs do not provide free HCV screening or interferon-based treatments that are expensive and beyond the affordability of these poor farmers”, said the report.
“While providing free HIV testing and treatment in these rural communities, Chinese government should make HCV testing available and affordable to these rural residents and consider HCV co-infection in training and patient care.”
Among the 3,062 villagers who were tested for both HIV and HCV, after being interviewed about their lifestyles and risk factors, HCV was more prevalent (12.7%) than HIV (1.3%). It is thought this may be so because HCV is transmitted more effectively via injections or unsterilised intravenous therapy equipment. It may also be more prevalent because HCV appeared among Chinese blood donors earlier (in the late 1980s) than HIV.
However the authors also noted that not all villagers participated in the study (85 percent participation rate) because, unlike many studies in China which enjoy close to 100 percent participation rate, the study team only tested those who gave informed consent after attending 'village health camps'. Most of those who did not participate were young - under 35 yeas old - and while most had standard reasons for not participating such as "too busy" or "out-migration for short term employment", some said they were not willing to be tested for HIV because they did not wish to know their status.
While HCV was much more prevalent, a significant number of those with HCV (8.7%) were also infected with HIV. And the majority of villagers with HIV were co-infected with HCV.The study authors said this group of people were likely to do very poorly, less likely to respond well to antiretroviral treatment and more likely to progress rapidly to AIDS.
“HCV may facilitate HIV disease progression, increase the incidence of liver toxicity associated with certain antiretroviral regimens, and represent a leading cause of morbidity and mortality among AIDS patients receiving antiretroviral therapy (ART)” said the report.
Blood and plasma selling was a widespread practice in the largely agricultural central Chinese provinces of Henan and Shanxi in the early 1990s where farmers struggled to earn enough to feed their families. After blood was collected from donors, an injection of pooled packed red cells of the appropriate blood group was given to enable donors to recover quickly between donations. Thus blood collection centres became a potent means of transmitting blood-borne infections such as HCV and HIV.
During the nineties, China moved from a socialist command economy with an extensive welfare system including primary healthcare, to a market economy where services, including healthcare have to be paid for. While average incomes have risen rapidly in China over the past decade, the biggest gains have been among urban Chinese. Rural Chinese have seen their incomes remain static or even drop, while their costs have risen.
Many farmers have sought alternative means of earning a living such as taking short-term factory work, travelling to the cities to work as 'rubbish pickers' for a few weeks after the harvest season, or until recently, selling their blood. In Qian et al's study, 29.5% of participants reported ever having sold blood or plasma to supplement their income.
Private blood collection centres started up in some of China's poorest agricultural provinces such as Henan, Shanxi, Shangdong, Anhui and Hebei in the late 1980s and prospered. Although all such centres have been officially banned, studies like this indicate their legacy, particularly the impact on China's health services, is only now being assessed.
"Our study findings underscore the importance of improved HIV treatment and prevention in rural, former plasma-donation communities, including diagnosis and basic care for HCV co-infection."
Qian, Han Zhu et al. Co-infection with HIV and hepatitis C virus in former plasma/blood donors: challenge for patient care in rural China AIDS 20: 1429–1435, 2006.