However much North Korean leader Kim Jong-un may say otherwise, HIV cases not only exist in the nation but are actually on the rise, particularly among people who inject drugs and people who donate or receive blood, Science reports.

The revelation stands in sharp contrast to what representatives for the Supreme Leader told World Health Organization officials at a gala on December 1,World AIDS Day: that North Korea is an “AIDS-free zone.”

According to Science, the first case of HIV in North Korea was identified in January 1999. But, per a report submitted by a team of North Korean and U.S. researchers to the online medical archive medRxiv, there were 8,362 people with HIV in North Korea in 2018—and a significant number of those cropped up within the past few years. The socialist country’s own National AIDS Commission estimates that around 0.069% of the total population has HIV. (For comparison, 0.6% of the total population of the United States has HIV.)

“That’s a pretty impressive takeoff,” noted Chris Beyrer, MD, a professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health in Baltimore who conducts HIV research in Asia.

North Korean public health officials thought so too. In 2013, they approached Taehoon Kim, a Korean-American humanitarian aid worker, for assistance with slowing the spread of the virus in rural areas. Kim is the cofounder of DoDaum, a New York City–based nonprofit that collaborates with the North Korean government on health, education and development programs. But he found his efforts repeatedly thwarted by something of a perfect storm of complicating factors, including a national lack of adequate diagnostic equipment, and bureaucratic red tape, including sanctions restricting the importation of antiretroviral medications into Pyongyang, the nation’s capital. He estimates that 30% to 40% of the antiretroviral meds that DoDaum had intended for North Koreans living with HIV were seized by Chinese customs officials at the border.

The situation left North Korean public health officials with a choice: to respect the wishes of the Kim Jong-un administration and keep quiet or do their duty to the people of North Korea and speak out.

“On the one hand, reporting the existence of these patients may lead to a backlash from the central government, as they are very much afraid of communicable diseases in general,” Kim Mun Song, a North Korean physician who works with the North Korean Ministry of Public Health, told Science. “On the other hand, not reporting and not recognizing the existence will perpetuate the issue of not having treatments.”

As the authors of the medRxiv report warn in a postscript, should the virus continue to spread, the North Korean government could take “austere measures” to contain it. This could include criminalizing HIV and detaining or deporting people living with the virus.