Are Chinese leaders finally getting serious about Aids? Premier Wen Jiabao's visit to an Aids ward at Beijing Ditan Hospital on Monday is the latest evidence of China's growing acknowledgement of its Aids crisis. Last month, senior Chinese officials held an extraordinary set of meetings with business leaders, nongovernmental groups and international organisations to discuss efforts to avoid a looming catastrophe. This positive shift in top-level commitment - and photo opportunities - is welcome, but it is insufficient to improve the critical area of local HIV/Aids policy implementation. Chinese Vice-Minister of Health Gao Qiang recently admitted that the country now has 840,000 HIV cases and 80,000 Aids patients. More than 150,000 have died since the first Aids case was reported in 1985. International experts believe the total number of cases could balloon to 15 million by 2010 if the government does not take immediate and comprehensive action. China's Aids victims are primarily young, undereducated and highly mobile. A substantial number of the estimated one million HIV carriers live in the countryside and are between 15 and 25. Some 68 per cent of infections are among intravenous drug users and 9.7 per cent among commercial blood donors. China has two high-profile HIV/Aids programmes. First, there is politically sensitive China Cares scheme, which seeks to provide free anti-Aids drugs and care for infected people who contracted the disease in the 1990s through contaminated blood transfusions. Second, there is the Joint 121 Action Plan, which aims, through education and awareness, to prevent the spread of Aids from high-risk groups into the general population through 'bridge populations' - which includes sex workers and the 130 million domestic labour migrants. These two ambitious projects are already showing signs of failure. Under China Cares, the central government has begun to provide domestically manufactured generic anti-retroviral drugs free to about 5,200 out of an officially estimated 35,000 HIV carriers in Henan province. The programme is intended to rectify the provincial government's lacklustre response to the spread of HIV among villagers who were selling their blood. To date, 1,040, or 20 per cent, of the participants have dropped out because of side-effects from the generic drugs. Without improvements to enable locals to provide the necessary quality of care and monitoring, more participants will abandon the programme. Frustration with the government's response has already led to an increase in civil unrest in some areas. Under China's Joint 121 Action Plan, universities and middle schools now have mandatory and effective Aids awareness and prevention classes. However, due to the involvement of local public security bureaus and the lack of a national system of anonymous testing, it is failing to reach marginalised high-risk groups. To rescue these schemes, China should consider two local-level reforms. First, Beijing should encourage the formation of independent HIV/Aids grassroots organisations by reducing the financial and structural requirements for their registration. Local HIV/Aids groups working independently of officials can effectively and quickly establish outreach groups to contact sex workers and habitual intravenous drug users. With proper training, members of these organisations can provide standardised care and counselling to victims, and establish orphanages for the increasing numbers of Aids orphans. Independent groups could also raise funds from overseas donors who want to make a direct impact. Second, local leaders need to be held accountable. Many local officials regard China's national Aids crisis as secondary to local economic goals and their political careers. At an Aids symposium for 300 medium-level officials last year, 19.2 per cent thought health officials who refused Aids patients treatment were in the right, and 6.4 per cent thought schools had the right to exclude children of Aids patients. Beijing's new-found commitment to fight Aids in co-operation with international organisations and other governments should be commended. But to avoid worst-case scenarios, the central government needs to actively involve all sectors of society, especially at the grassroots level, and remove local institutional barriers that hinder effective and sustained policy implementation. Edmund Settle is the author of Aids in China: an annotated chronology 1985-2003, and founder of the website: China Aids Survey ( www.casy.org )