It is feared well-off and upwardly mobile business people in China's largest cities may be contracting and spreading HIV/AIDS - and many do not even know they are infected.
Figures are sketchy but "mobile men with money," as experts have dubbed the group, are a growing concern as the country battles to halt the epidemic.
"There is an emerging division in the business. There's starting to be people who work on mobile men with money," said Tim Manchester, director of Futures Group, a private organization that focuses on preventing the spread of HIV/AIDS.
What HIV/AIDS professionals are wondering - as are doctors at government-funded organizations such as the centre of disease control and hospitals in Shanghai - is whether mobile men with money will prove to be a gateway for the disease into large cities.
"That's everybody's concern, that it's a bridge population," said Manchester. "We are not seeing that yet because the testing is not there yet."
A possible scenario is that of a businessman who does not use condoms and even pays extra for a prostitute who ignores the risk to earn more money but is infected, whether she knows it or not. He becomes infected and then passes the infection to his wife who goes on with her life completely unaware of the disease she is carrying.
"It never occurs to you that you might have AIDS," said Manchester.
Most people infected in China do not know.
The number of cases detected every year is rising. A few years ago, the average number of new cases detected in Shanghai was between 60 and 70 per year. In 2002 there were about 100 and that almost doubled in 2003. By 2004, the number of new cases was up to 239.
That is the number of known cases, said Pan Xiaozhang, an HIV/AIDS specialist at Huashan Hospital in Shanghai.
"We don't know about most cases of infection."
He estimated there could be between 8,000 and 10,000 other cases in Shanghai.
"I think the situation is not good. Just according to my information, the number of undetected infections is getting higher.
"I think transmissions through (unprotected) sex is the major road.
"The situation is different from Sichuan and Yunnan provinces where most people were infected by intravenous drug use.
"In Shanghai, prostitutes and people who (use) prostitutes are most vulnerable."
Although a large portion of China's infections were the result of tainted blood donations or transfusions and, later, intravenous drug use, most new cases are now the result of unprotected sex.
Condom use in China is still not common and prostitutes can earn up to 60 percent more money for providing unprotected sex, according to studies by UNAIDS a United Nations project on HIV/AIDS.
The groups traditionally identified as vulnerable in China - migrants and prostitutes as well as poor people who donate blood in exchange for money - all have programs in place to help curb the spread of the disease.
Fears the floating population of migrant workers might be the biggest threat to China's cities first started to surface about a year and a half ago. There is therefore a lot of work being done to control the spread among this group and much of it is working,
But more affluent groups may be beyond the reach of such programs. They are rarely tested and, in all the literature available, they are seldom mentioned.
"The data never analyses this. I think it's a problem," said Pan. "I think we should look at this question."
Awareness of HIV/AIDS in China is growing, if slowly, and the number of programs to help people living with the disease is growing every day. At the same time, prevention efforts have gone a long way to largely keeping the virus out of urban centers.
Since the first case of HIV was uncovered in China in 1985, the virus has spread to every province. Still, in big cities like Shanghai, the reported numbers have been relatively small.
In Shanghai, since the virus was first detected in 1987 up until 2004, there have been 1,150 officially detected cases. Given a population that tops 12 million, the incidence is less than 0.01 percent.
That's the number of known cases. But UNAIDS studies have shown about 90 percent of those infected in China are unaware.
Most of these affected people are migrants or prostitutes, but programmes already in place to control the epidemic among these groups are already having some effect. That leaves another open question.
"Everybody has been assuming that the big problem is the migrant workers moving into the cities, but we disagree vehemently," said Manchester.
At the same time, it is the more affluent section of the community that is more likely to have unprotected sex or buy the services of prostitutes.
Most of the data available on mobile men with money is anecdotal and the fears among workers are educated guesses at this point, but it is difficult to ignore the numbers.
Household surveys carried out by UNAIDS and Futures over the past few years show that between 5 and 10 percent of men in Asia buy sex.
According to UNAIDS's estimation, 20 percent of some 6 million prostitutes in China do not use condoms.
Men in the upper 5 percent of income earners are 33 times more likely to use prostitutes than people in the lowest 40 percent, according to a study commissioned by the Futures Group and carried out by Horizons research.
At the same time, said Manchester, data has shown that men who are away from home more than five days a month are much, much more likely to use prostitutes.
"The propensity to use prostitutes shoots through the roof," he said.
Plenty of programs are available for migrant workers but they are much less likely to have the funds to use prostitutes than business people out for meetings away from home.
At the end of a hard day's work, they want to be fed, they want a shower and they want to go to sleep, said Manchester.
Business people, on the other hand, have late night dinners with colleagues and, as often as not, cap those off with obligatory toasts that sometimes lead to visits to massage parlours, KTV establishments or bathhouses where prostitutes are available.
The lack of hard statistics is a problem. There is "no formal survey of this kind of group," said Wu Zunyou, a doctor at the China Center for Disease Control and Prevention.
It is a highly sensitive topic and the government only knows about this group through their use of sex clinics.
Mobile men with money are on virtually nobody's radar right now.
The responsibility for finding solutions may rest with the corporations that employ many of these men.
A Global Business Coalition focusing on HIV/AIDS already exists. It uses business resources to tackle the spread of the disease.
"Mobile men with money are usually working with somebody and, if they are working for somebody why can't we get something going," said Manchester.
The coalition met representatives from the Ministry of Health in March. At the time, a consensus was reached to work together to find ways to fight the disease.
Efforts to unite the business community have been reasonably successful in Beijing, said Bill Valentino, Bayer's manager of public relations and the coalition point man in China.
"There's a lot more engagement in Beijing," he said.
What is needed, said Valentino, are corporate policies to protect employees and give them the privacy they need to get tested without fear of repercussions.
"Here, when you talk to an employer, there is no guarantee of what may happen," he said.
"You don't know where the information is going. It's a very big issue."
(China Daily August 2, 2005)
