H.I.V. Tests Turn Blood Into Cash in China

http://www.nytimes.com/2009/12/03/health/policy/03china.html?_r=1&scp=3&sq=china%20aids&st=cse
Du Bin for The New York Times
Patrons of the Purple Tribe nightclub in Tianjin, China, can earn money for taking an H.I.V. test, part of a Gates Foundation initiative that has drawn criticism.
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By ANDREW JACOBS
Published: December 2, 2009
TIANJIN, China — A young, boisterous crowd gathered in front of the Purple Tribe nightclub on a recent Friday night, but hardly anyone was interested in going inside.

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Times Topics: China
Health Guide: AIDS
Instead the men, most of them gay, waited their turn to duck into a dingy storage space next to the club. A needle prick and a wince later, they emerged with a triumphant grin, having exchanged a test tube of blood for a pocketful of cash. “This is my third time in two weeks,” Zhang Haoyun, an 18-year-old store clerk, boasted as he walked away holding a cotton swab to the bend of his arm.

On any given night, in 14 cities around the country, hundreds of people flock to makeshift blood collection centers in bars, bathhouses and apartments where workers test for syphilis and H.I.V., the virus that causes AIDS. The ambitious testing initiative, started in 2007, is financed by the Bill & Melinda Gates Foundation, which will spend $50 million over five years in an effort to slow the spread of AIDS in China. So far, more than 110,000 people have been tested.

But the Gates H.I.V. prevention program in China is unusual because it offers a financial incentive to those drawing the blood — about $9 per sample and an additional $44 for those that come back positive — which is shared with donors. The program has provoked a flurry of criticism from some established AIDS organizations that say the money has given rise to a network of fly-by-night groups whose only interest is collecting money.

Here in Tianjin, a northern city of 11 million people, two dozen organizations have sprung up in the past year, many of them run by bar owners or bureaucrats affiliated with the government. Some of the groups do not provide counseling to those giving blood and make little effort to help those who test positive get medical treatment.

“Gates has created a huge blood-buying operation that only cares about money, not about people,” said Ma Tiecheng, who runs a seven-year-old AIDS organization in the northwest city of Shenyang. “I’ve seen people getting four H.I.V. tests a day.”

With more than $3 billion in annual giving, the Gates Foundation tends to make waves wherever it directs its largess. It is widely lauded for taking on malaria, tuberculosis and AIDS, among the biggest killers in the developing world, but it has aroused criticism for what some describe as the foundation’s resistance to outside viewpoints when charting its programs. Others complain that the huge grants alter the local health care landscape by creating a realm of haves and have-nots among grass-roots organizations.

Here in China, the foundation’s stated mission is to identify H.I.V.-infected people as the first step in getting them treated. Those who know their status, architects of the program say, are also more likely to modify behavior that puts others at risk. The payments, they say, are crucial for bringing people face to face with outreach workers.

Although not trumpeted in its promotional materials, the foundation’s other goal is more far-reaching: to empower the small but growing crop of nongovernmental groups that stand a better chance of addressing the AIDS epidemic than China’s lumbering bureaucracy does.

To carry out its mission, the foundation has linked up with the Ministry of Health, which funnels $20 million to about 200 nonprofits, many of which exist in a bureaucratic gray zone and are viewed suspiciously by China’s authoritarian government.

The distrust flows both ways.

By compelling the government to work with privately run organizations, the foundation is hoping to foster a lasting relationship between them — and over time contribute to creating more profound changes in Chinese society.

Dr. Ray Yip, who runs the foundation’s China effort, acknowledges problems with the program but likens them to growing pains.

“We are experiencing some of the hiccups of a less-than-perfect arrangement, but we expected that,” he said. “If you look historically at arranged marriages, some of them last.”

Dr. Yip, who is the former director of the Centers for Disease Control and Prevention office in China, embraces the Gates Foundation’s philosophy of bold initiatives and risk taking — traits often lacking in government-run global health behemoths. He said that if some of the money ended up in the pockets of corrupt officials running fake organizations, it was the cost of doing business in China, where government malfeasance is endemic.

“We don’t expect every grant in every city to be spectacularly successful,” he said. “That’s like buying 30 stocks and expecting them all to go up.”

Sun Jiangping, deputy director of China’s National Center for AIDS/STD Control and Prevention, said the program had already had a positive impact on government attitudes toward private AIDS organizations, whose numbers have increased to more than 400 from just a few dozen when the initiative started. He said his agency was working to weed out illegitimate groups.

Compared with the rates in other developing nations, the prevalence of H.I.V. in China is relatively low, with fewer than a million people thought to be infected, according to government figures released last week.

But public health experts are alarmed by an infection rate among gay men that has been doubling annually. By the end of 2008, nearly 5 percent of gay men in China’s largest cities were thought to be H.I.V. positive; in some cities, that figure exceeds 10 percent. Health officials say gay men now account for a third of all new transmissions, up from 12 percent in 2007.

Advocates for people with AIDS say the government has been ham-handed in its efforts to prevent the spread of H.I.V., in some cases banning condoms in bars or hounding activists who become too vocal.

In recent years, organizations have sprung up to help those with AIDS who are refused care by hospitals. Many, like Deep Blue, a group that operates from an apartment on the outskirts of Tianjin, are largely financed by grants from abroad.

Deep Blue’s two counselors meet with the 50 people who come each week for an H.I.V. test.

“If you have any questions, contact the volunteers with the red armbands,” says one poster. “You can stop the testing at any time,” says another. About 65 percent of those who test positive come back for counseling, said the group’s director, Yang Jie.

Tong Ge, a veteran AIDS activist who has advised the Gates Foundation on its China program, said he was pleased with the foundation’s work, though he said he wished there was more of an emphasis on training government workers and less money spent on testing. His biggest regret, he said, is that the foundation chose to funnel the money through the government.

“So much of the Gates money has ended up nurturing corruption in a place it didn’t exist before,” he said. Then, after a pause, he added: “But the truth is we can’t blame them. The real problem is with China.”

Zhang Jing contributed research.

Next Article in Health (18 of 44) »A version of this article appeared in print on December 3, 2009, on page A6 of the New York edition.