Five thalassemia children contract HIV in MP, health system failed to act for months

For a father in Satna, the shock came in waves. When doctors told him that his 15-year-old daughter — a thalassemia patient dependent on regular blood transfusions — had tested HIV positive, disbelief gave way to dread. He insisted on a repeat test. The result was the same. “My wife and I are HIV negative. We don’t know how this happened,” he said.

His daughter is one of five children with thalassemia who tested positive for HIV between March and April this year after receiving blood transfusions at government and private hospitals in Madhya Pradesh’s Satna district. Yet, for months, the infections failed to trigger alarm bells across the state’s health system.

An investigation based on interviews with members of the inquiry committee and officials from district and state health departments, the AIDS Control Society and the State Blood Transfusion Council, reveals a systemic breakdown marked by silence, delay and poor coordination.

Infections confirmed, but not formally reported

Officials acknowledged that HIV infections confirmed in March and April were never documented in writing to hospital management or senior state authorities. While district-level officials tracked cases and prepared transfusion histories, the information remained confined to the local AIDS Control Society.

As a result, the State Blood Transfusion Council learnt of the infections only months later, closing the window for swift, statewide preventive action.

The consequences are stark. Of nearly 200 blood donors linked to the transfusions, only 10 to 12 have been successfully traced so far. Phone numbers were incorrect or disconnected; some donors had moved out of state, while others refused testing. The massive exercise is being handled by a team of just two people.

A pattern across hospitals

District hospital records show that all five children received transfusions at the Satna district hospital, while three also received blood at a private hospital.

The first case involved a 15-year-old girl who tested HIV positive on March 20 after undergoing 126 transfusions. A nine-year-old boy tested positive on March 26 after 24 transfusions. Two days later, another nine-year-old boy, who had received 26 transfusions, was diagnosed. A fourth case — a 15-year-old boy with 13 transfusions — was confirmed on April 3. The youngest patient, a three-year-old girl who had received nine transfusions, tested positive on April 1.

In four of the five cases, both parents tested HIV negative, strengthening concerns that the infections were linked to medical procedures.

Notice issued after nine months

It was only on December 16 — nine months after the first infection was confirmed — that Satna Civil Surgeon Dr Manoj Shukla issued a formal notice to the district AIDS control nodal officer, Dr Pooja Gupta, seeking an explanation for the alleged lapses.

In the notice, Shukla wrote that HIV infections confirmed in March–April 2025 were not formally communicated to hospital management or senior authorities, adding that the failure had “tarnished the image of the hospital management” and drawn the displeasure of higher officials.

Shukla later said that while internal processes were initiated, no written communication was sent to hospital authorities. “Local officials processed the cases and tracked donors, but nothing was officially conveyed to us,” he said.

Dr Gupta said senior officials were informed orally when the first case emerged. “Because of the sensitive nature of the case and to protect the child’s identity, it was not put down in writing,” she said, adding that donor verification began within days and that all traceable donors tested HIV negative.

‘Handled as a routine process’

Ruby Khan, Deputy Director of the State Blood Transfusion Council and a member of the six-member inquiry committee, said the emphasis on confidentiality came at the cost of timely escalation.

“This was handled as a routine process. Information did not reach the state level; otherwise, action would have been taken earlier,” Khan said. She confirmed that the state is now drafting fresh guidelines mandating immediate reporting by districts.

Health officials maintain that all transfusions were conducted after mandatory testing, in line with National AIDS Control Organisation norms. They point to the HIV window period, during which antibodies may not be detected, as one possible explanation.

Even so, donor tracing remains the investigation’s biggest hurdle. “There is stigma, refusal for retesting, and logistical barriers in rural areas,” Shukla said, adding that unsafe medical practices outside hospitals are also being examined.

Questions without answers

For the families, official explanations offer little comfort. The father of the 15-year-old girl said his daughter had been receiving transfusions since she was nine, initially once a month, later as often as three times a month as her condition worsened.

She received transfusions at facilities in Jabalpur and Satna over the years, but all recent transfusions were through the Satna district hospital blood bank, he said.

Months after the infections surfaced, the investigation is still trying to determine when and where the children contracted HIV. For parents watching their children battle both thalassemia and HIV, the delay has already exacted a devastating cost.