Childhood adversity and cognitive impairment in later life

Objectives

This study examined the association between childhood adversity and cognitive impairment in later life and explored the potential moderation effect of gender and race.

Methods

The study sample included 15,133 participants of the Health and Retirement Study (1998-2016 surveys) who had complete data on key study measures and were more than 50. The outcome variable is a dichotomous indicator of cognitive impairment as assessed by the Telephone Interview for Cognitive Status for self-respondents and the 16-item Informant Questionnaire on Cognitive Decline in the Elderly for proxies. A total of six childhood adversity indicators included grade retention, parental substance abuse, physical abuse, trouble with the police, moving due to financial hardship, and receipt of help due to financial hardship in early life. The estimation of the association between childhood adversity and cognitive impairment involved Cox proportional hazards regression. Results: Grade retention had the largest effect on incident cognitive impairment (HR = 1.3, 95% CI = 1.23-1.38, p < 0.001), followed by physical abuse by a parent (HR = 1.10, 95% CI = 1.00-1.20, p = 0.001). The impact of grade retention was more detrimental to women than men (interaction term HR = 0.89, 95% CI = 0.80-1.00, p = 0.048, female as the reference). Parental substance abuse was associated with a lower risk of incident cognitive impairment for most racial groups (HR = 0.89, 95% CI = 0.83-0.95, p = 0.001), but this association was reversed in "non-Hispanic other" race, consisting mainly of Asians (HR = 1.54, 95% CI = 1.05-2.26, p = 0.025).

Discussion

Some aspects of childhood adversity continue to harm cognitive functioning in later life, while some events may have the opposite effect, with evidence of heterogeneity across gender and race.

The varieties of religious experience and the retention of clients in Taiwanese faith-based residential drug user treatment

This study investigated whether subgroups of faith-based treatment clients displaying similar religious experiences and treatment performance can be theoretically specified and empirically identified. Highlighting the volitional dimension of the change process, four subgroups (i.e., non-Christians, baseline Christians, rededicated Christians, and newly converted Christians) were proposed according to the direction and magnitude of clients' change in religiosity during treatment. Data obtained for 707 subjects who entered a Christian residential therapeutic community program in Taiwan between 2000 and 2009 were analyzed. Results showed that the typology of religious experiences powerfully predicted treatment retention and completion. Issues of therapeutic specificity and relapse prevention are discussed and study's limitations are noted.

Scaling up the national methadone maintenance treatment program in China: achievements and challenges

China’s methadone maintenance treatment program was initiated in 2004 as a small pilot project in just eight sites. It has since expanded into a nationwide program encompassing more than 680 clinics covering 27 provinces and serving some 242 000 heroin users by the end of 2009. The agencies that were tasked with the program’s expansion have been confronted with many challenges, including high drop-out rates, poor cooperation between local governing authorities and poor service quality at the counter. In spite of these difficulties, ongoing evaluation has suggested reductions in heroin use, risky injection practices and, importantly, criminal behaviours among clients, which has thus provided the impetus for further expansion. Clinic services have been extended to offer clients a range of ancillary services, including HIV, syphilis and hepatitis C testing, information, education and communication, psychosocial support services and referrals for treatment of HIV, tuberculosis and sexually transmitted diseases. Cooperation between health and public security officials has improved through regular meetings and dialogue. However, institutional capacity building is still needed to deliver sustainable and standardized services that will ultimately improve retention rates. This article documents the steps China made in overcoming the many barriers to success of its methadone program. These lessons might be useful for other countries in the region that are scaling-up their methadone programs.

Drug addiction in China

Drug addiction in China began with the importation of Indian opium by the British in the 16th century and brought severe social and health problems. While drug abuse abated following the establishment of People's Republic of China, modernization and Westernization in the 1980s led to the reemergence of this problem. Drug abuse in China became epidemic, facilitating the spread of HIV/AIDS. The Chinese government has made great efforts to address these problems, focusing both on treatments of drug addiction and on harm-reduction programs. Although the new trends of drug addiction in China pose great public health challenges, these government interventions are likely to successfully stem the problem of drug abuse in the future.

Comparison of drug abuse in Germany and China

Drug abuse has a long, but also different history in Germany and China. The Opium War largely influenced the history of China in 19th century; however, China was once recognized as a drug-free nation for 3 decades from the 1950s to the 1980s. Drug abuse has spread quickly since re-emerging as a national problem in China in the late 1980s. The number of registered drug abusers increased from 70 000 in 1990 to more than 1 million by the end of 2005. In past decades, illicit drug trafficking and production have swept most provinces in China, and drug abuse has caused many problems for both abusers and the community. One major drug-related problem is the spread of HIV, which has caused major social and economic damage in China. Germany, the largest developed European country, also faces the drug and addiction problem. Germany has about 150 000 heroin addicts, for whom HIV/AIDS has become a serious threat since the mid 1980s. To control the drug problem, the German Government adopted the “Action Plan on Drugs and Addiction” in 2003; the China Central Government approved a similar regulation in the antidrug campaign in 2005. Germany has experience in reducing drug-related harm. The methadone maintenance treatment (MMT) program has run for more than 20 years and the public has become more tolerant of addicts. In 2003, China began the MMT program for controlling the spread of HIV/AIDS. It is necessary for China to learn from developed countries to acquire success in its antidrug campaign. In this review, we will go over the differences and similarities in drug abuse between Germany and China. The differences are related to history, population and economics, drug policy context, drug laws, HIV/hepatitis C virus infection, the MMT program and so on. These 2 nations have drug abuse problems with different histories and currently use different approaches to handle illicit drug marketing and use. The legal penalties for illicit drug offences reflect the social differences of these 2 nations with respect to the seriousness of particular types of crimes. The characteristics of the MMT program may also influence patterns of drug abuse in these 2 nations and China should improve the MMT program based on the successful model in Europe, the USA, and Australia. We recommend more dialogue and collaboration between Germany and China.

Improving drug addiction treatment in China

AIMS

To illustrate the current situation and problems of drug addiction in treatment China and propose suggestions.

METHODS

A descriptive study based on literature searched from Medline and the China National Knowledge Infrastructure database (1996-2007) and hand-picked references.

RESULTS

Since the re-emergence of drug addiction in China in the early 1990s, there has been tremendous progress in drug addiction treatments in China, especially treatments for opiate addiction. However, many problems and challenges remain for improvement, including widespread negative attitudes towards drug abuse and drug-dependent individuals, the lack of evidence-based data on the efficacy of Chinese traditional medicine and the lack of a comprehensive and integrated system to organize all treatment resources and monitor treatment progress. The authors discuss the challenges that impede effective treatments of drug addiction and some suggestions are proposed. Implementing these suggestions can improve the outcome of treatment of drug-dependent individuals and benefit the whole society.

CONCLUSION

China faces substantial drug addiction problems that appear to be worsening with time. Although much progress in drug addiction treatment has been made, improvement in many aspects is needed urgently.

Rapid scale up of harm reduction in China

In the last 20 years, China has seen a resurgence in drug use, particularly heroin, and with it a growing epidemic of HIV/AIDS. Faced with this dual epidemic, the government has begun testing harm reduction strategies in recent years. These have included methadone maintenance treatment (MMT) programmes, needle-syringe programmes (NSP), outreach, and increasing access to HIV testing. MMT and NSP have moved from the pilot stage to scale-up, with 320 MMT clinics and 93 NSPs now open. Both will number more than 1000 by the end of 2008. There are some good examples of outreach programmes in some areas, however more needs to be done to facilitate greater involvement from non-government organizations. Similarly, HIV testing for drug users is widely available, but novel approaches to increasing its uptake need to be explored. Management of scale-up and reaching China's vast and dispersed drug-using population remain key challenges. The introduction of harm reduction has been a massive turn-around in thinking by the government, particularly law enforcement agencies, and achieving this has required considerable cooperation and understanding between the Ministries of Health, Public Security, and Justice, and the Food and Drug Administration. With their support, rapid scale-up to effectively reach a majority of drug users can be achieved in the coming years.

Expansion of HIV/AIDS in China: lessons from Yunnan Province

In this article we systematically and critically review the Chinese and English language literature on human immunodeficiency virus (HIV)-related studies in Yunnan Province, Southwestern China. Yunnan Province had the first Chinese HIV outbreak and is still the worst affected area in the nation. Since 1989, HIV infection has extended from injecting drug users into the general population through sexual transmission. Since the economic reform of the 1980s, changed social norms and increased migration have spawned increases in HIV-related risk behaviors such as drug use and commercial sex work. A smaller size of "bridge" populations and lower sexual contact rates between persons in "bridge" and general populations may explain the slower expansion of the HIV epidemic in Yunnan compared to nearby Southeast Asian nations. In 2004, women in antenatal care had a 0.38% HIV prevalence province wide, although >1% infection rates are seen in those counties with high injection drug rates. Patterns of drug trafficking have spread the unusual recombinant HIV subtypes first seen in Yunnan to far-flung regions of China. Increased efforts of Yunnan's HIV control program are correlated with an improved general HIV awareness, but risk behaviors continue at worrisome rates. Future efforts should focus on changing risk behaviors, including harm reduction and condom promotion, especially among the "bridge" groups. The resurgence of commercial sex work in Yunnan, and the high frequency of workers migrating into provinces far from home and family are all sociocultural factors of considerable importance for future HIV and sexually transmitted disease control in China.

Opiate addiction in China: current situation and treatments

BACKGROUND

Historically, China has had extraordinarily high rates of opiate dependence. These rates declined drastically following the 1949 revolution; however, opiate abuse has re-emerged in the late 1980's and has spread quickly since then.

AIMS

To describe the current situation of opiate addiction and treatments in China and make some suggestions.

DESIGN

A descriptive study based on literature searched from Medline and the China National Knowledge Infrastructure database (1996 to 2004) and hand-picked references.

FINDINGS

The number of registered addicts in 2004 was 1.14 million (more than 75% of them heroin addicts), but the actual number is probably far higher. Opiate abuse contributes substantially to the spread of HIV/AIDS in China, with intravenous drug use the most prevalent route of transmission (51.2%). Currently, the main treatments for opiate dependence in China include short-term detoxification with opiate agonists or non-opiate agents, such as clonidine or lofexidine; Chinese herbal medicine and traditional non-medication treatments are also used. Methadone maintenance treatment (MMT) has not been officially approved by the Chinese government for widespread implementation, but some pilot studies are currently underway.

CONCLUSION

China faces substantial drug abuse problems that appear to be worsening with time. Opiate dependence is a major threat to the public health and social security of China because of its devastating medical effects, its impact on risk for HIV/AIDS and criminal behaviors, low rates of recovery and high rates of relapse. There is an urgent need to implement MMT and other modern treatments for opiate dependence more widely in China.

Modeling the HIV/AIDS epidemic among injecting drug users and sex workers in Kunming, China

This paper presents a mathematical model of the HIV/AIDS epidemic in Kunming, the provincial capital of Yunnan, China. The population is divided into several groups, with individuals possibly changing group. Two transmission routes of HIV are considered: needle sharing between injecting drug users (IDUs) and commercial sex between female sex worker (FSWs) and clients. The model includes male IDUs who are also clients and female IDUs who are also FSWs. Groups are split in two--risky and safe--according to condom use and needle sharing. A system of partial differential equations is derived to describe the spread of the disease. For the simulation, parameters are chosen to fit as much as possible data publicly available for Kunming. Some mathematical properties of the model--in particular the epidemic threshold R0 which determines the goal of public health interventions--are also presented. Though the model couples two transmission routes of HIV, the approximation R0 approximately = max[R0(IDU), R0(sex)], with closed formulas for R0(IDU) and R0(sex), appears to be quite good. The critical levels of condom use and clean needle use necessary to stop both the sexual transmission and the transmission among IDUs can therefore be determined independently.

Characterization of HIV type 1 heterosexual transmission in Yunnan, China

The earliest HIV-1 epidemic in China started in Yunnan province, which continues to be one of the most severe areas affected. While HIV-1 infections are spreading rapidly among injection drug users (IDUs) in China, sexual transmission of HIV-1 has also been confirmed, threatening the general population. Recent survey data indicated that heterosexual transmission of HIV-1 in Yunnan was steadily increasing. Diverse HIV-1 strains, including subtype B, C, CRF01, and CRF08, are circulating among individuals who acquired HIV through sexual contacts. Multiple HIV-1 subtypes, including subtypes B, C, and CRF08, were also detected among IDUs. In comparison with other IDU cohorts, intersubject env sequence variation was much higher amongIDUs in Yunnan. Growing evidence suggests that unprotected sex continues to occur at high rates among IDUs and their sex partners. Intervention strategies are urgently needed to target individuals at high risk for HIV heterosexual transmission and injection drug use. The complex pattern of HIV-1 distribution in the high-risk populations in Yunnan may have important implications for HIV transmission as well as vaccine development and evaluation.

AIDS and public policy: the lessons and challenges of "success" in Thailand

Thailand's public policy on AIDS is widely cited as one of the few examples of an effective national AIDS prevention program anywhere in the world. The Thai experience shows that a national response that mobilized key government and NGO partners and targeted the highest-risk transmission can be effective in reducing the scope of the epidemic, even when action is delayed. Based on interviews with policymakers, AIDS program managers, technical specialists, donors, and NGOs and on a review of the data, we highlight the lessons from public policy on AIDS in Thailand for other developing countries, review the state of the Thai epidemic and public policy in 2000, and identify three strategic priorities for the next phase of the response.

Illicit drug initiation among institutionalized drug users in China

AIMS

To examine the circumstances and correlates associated with initiation of illicit drug use among institutionalized drug users in China.

DESIGN

Cross-sectional, retrospective study.

SETTINGS

Six compulsory drug cessation programs in Yunnan Province and Gunagxi Zhuang Autonomous Region of China.

PARTICIPANTS

A gender-stratified random sample of 833 drug users (88% males and 12% females) enrolled in compulsory drug cessation programs in November 1996.

MEASUREMENTS

Circumstances of illicit drug initiation (age, type of drugs, routes of drug administration, social setting, source of drugs, reasons for drug use), the risk behaviors and risk perceptions prior to drug initiation.

FINDINGS

The majority of participants initiated drug use with heroin (90%). Initial drugs were frequently administered through sniffing/snorting (55%) and smoking cigarettes mixed with a drug (38%). First drug use occurred most commonly at a friend's home (65%) and in the company of other drug users (83%). Drugs were generally provided free for first-time use by other drug users (72%). Reasons for first drug use included experimentation (90%), being lured into drugs by other people (44%) and relaxation (42%). Most drug users had a history of regular cigarette smoking (89%), alcohol consumption (49%) and deviant behaviors (51%) prior to their drug initiation. The majority perceived that their friends (90%) and neighbors (88%) used illicit drugs.

CONCLUSIONS

The findings are similar to studies in western countries with respect to the pattern and correlates of illicit drug initiation, and underscore the need for drug prevention efforts in China.

Reawakening the dragon: changing patterns of opiate use in Asia, with particular emphasis on China's Yunnan province

Asian countries adjacent to the Golden Triangle and their neighbors have witnessed an evolution in "drug abuse" from traditional opium smoking to heroin eating, smoking, and finally heroin injection. A recent study of 630 heroin users was conducted in China's Yunnan Province, located close to the Golden Triangle. Data collected between August 1997 and February 1998 indicate injecting heroin users, in comparison to noninjectors, were more likely to have used drugs for a longer period of time, and to use drugs more frequently everyday. Other major differences existed between urban and rural subjects, especially highlighting differences between men and women. Women comprised a much higher proportion of urban subjects than rural subjects. Rural injectors were much more likely to be male, but urban injectors were almost evenly split between men and women. The emerging epidemic of heroin use in China and the continuing substance abuse problem in the United States provide an opportunity for collaborative research of mutual benefit.

Injection Drug Use and Unprotected Sex among Institutionalized Drug Users in China

The current study was designed to examine injection drug use practices (injecting drugs and needle sharing) and unprotected sexual behaviors (multiple sexual partners, failure to use a condom) among drug users in China. Data were obtained from 833 institutionalized drug users in southwest China. More than two-thirds of the sample reported frequent intravenous or intramuscular drug-injection. Among injection drug users (IDUs), 78% shared needles. Compared to non-IDUs, IDUs who also shared needles had significantly higher rates of having multiple sexual partners (73% versus 54%, p<.001) and of never having used a condom (71% versus 56%, p<.01). The data in this study suggest that IDUs comprise a high-risk population for HIV infection in China and underscore the urgency for preventing injection drug use and unprotected sexual practices among drug users in China.

Emerging HIV infections with distinct subtypes of HIV-1 infection among injection drug users from geographically separate locations in Guangxi Province, China

Heroin users from Guangxi province, a southern province of China that borders Vietnam in the south and Yunnan province in China in the west, were studied for prevalence and risk factors for HIV-1 infection. Viral env sequences from HIV-1-positive individuals were also determined for subtypes of HIV-1. The overall HIV prevalence among 227 heroin users was 40%. Most had used drugs for < or = 3 years. Sharing of injection equipment and unprotected sex were significantly associated with HIV-1 infection. Subtypes C and E HIV-1 were detected in infected heroin users and were sharply segregated in two geographic locations: only subtype C was found in a border city with Yunnan province, whereas only subtype E was found in a city bordering northern Vietnam. HIV-1 strains within each subtype were remarkably homogenous, with a mean intersubject DNA distance of 2.32% for subtype E and 1.13% for subtype C, respectively. Phylogenetic analysis of C2-V5 region of Guangxi subtype E env sequences revealed significant clustering with subtype E sequences from southern Vietnam and Cambodia. These results suggest that HIV-1 infection among heroin users in Guangxi represents two emerging epidemics initiated from distinct sources: one from Vietnam and another from Yunnan province. Factors associated with HIV-1 infection were not restricted to injection practices. Unprotected sexual behaviors are likely to increase the probability of HIV transmission beyond this high-risk population. Designing and implementing effective intervention strategies targeted toward both injection drug use and high risk sexual behavior are urgently needed to further reduce HIV-1 spread in China.