Injection drug use and HIV/AIDS in China: review of current situation, prevention and policy implications

Trends of HIV, hepatitis C virus and syphilis seroprevalence among injection and non-injection drug users in southwestern China, 2010-2017

Background: The primary risk of HIV transmission in China has shifted from injecting drug use (IDU) to sexual contact since 2006. We evaluated the prevalence trends of HIV, hepatitis C virus (HCV), syphilis, and sexual and drug use behaviors among drug users. Methods: People who use drugs participated in any of four rounds of cross-sectional surveys during 2010-2017 in Chongqing. Participants were tested for HIV, HCV, and syphilis. Questionnaire interviewing was conducted to collect behavioral information. Chi-square and trend tests were employed to assess the changes in diseases and behaviors over time. Results: A total of 8,171 people who inject drugs (PWID) and 5,495 non-injection drug users (NIDU) were included in the analyses. HIV prevalence among PWID in four rounds of the survey in 2010-11, 2012-13, 2014-15, and 2016-17 was 11.5%, 9.7%, 6.5%, and 6.9%, and among NIDU, 2.4%, 1.4%, 2.1% and 2.6%, respectively. HCV prevalence among PWID was 83.5%, 85.2%, 67.1% and 79.7% (P < 0.001), and among NIDU, 22.2%, 10.8%, 13.4% and 14.8%, (P < 0.001). Conclusions: The declining HIV and HCV prevalence among PWID is coincident with declining risky drug use behaviors. Tailored disease prevention and interventions targeting PWID and NIDU are needed.

The estimation of long and short term survival time and associated factors of HIV patients using mixture cure rate models

BACKGROUND

HIV is one of the deadliest epidemics and one of the most critical global public health issues. Some are susceptible to die among people living with HIV and some survive longer. The aim of the present study is to use mixture cure models to estimate factors affecting short- and long-term survival of HIV patients.

METHODS

The total sample size was 2170 HIV-infected people referred to the disease counseling centers in Kermanshah Province, in the west of Iran, from 1998 to 2019. A Semiparametric PH mixture cure model and a mixture cure frailty model were fitted to the data. Also, a comparison between these two models was performed.

RESULTS

Based on the results of the mixture cure frailty model, antiretroviral therapy, tuberculosis infection, history of imprisonment, and mode of HIV transmission influenced short-term survival time (p-value < 0.05). On the other hand, prison history, antiretroviral therapy, mode of HIV transmission, age, marital status, gender, and education were significantly associated with long-term survival (p-value < 0.05). The concordance criteria (K-index) value for the mixture cure frailty model was 0.65 whereas for the semiparametric PH mixture cure model was 0.62.

CONCLUSION

This study showed that the frailty mixture cure models is more suitable in the situation where the studied population consisted of two groups, susceptible and non-susceptible to the event of death. The people with a prison history, who received ART treatment, and contracted HIV through injection drug users survive longer. Health professionals should pay more attention to these findings in HIV prevention and treatment.

Effectiveness of a mobile-based HIV prevention intervention for the rural and low-income population involving incentive policy to doctors in Liangshan, China: a randomized controlled trial protocol

Background

The HIV/AIDS epidemic is a concerning problem in many parts of the world, especially in rural and poor areas. Due to health service inequality and public stigma towards the disease, it is difficult to conduct face-to-face interventions. The widespread use of mobile phones and social media applications thus provide a feasible and acceptable approach for HIV prevention and education delivery in this population. The study aims to develop a generalizable, effective, acceptable, and convenient mobile-based information intervention model to improve HIV-related knowledge, attitudes, practices, and health outcomes in poverty-stricken areas in China and measure the impact of incentive policies on the work of village doctors in Liangshan, China.

Methods

A randomized controlled trial design is used to evaluate the effectiveness of an 18-month mobile-based HIV prevention intervention, collaborating with local village doctors and consisting of group-based knowledge dissemination and individualized communication on WeChat and the Chinese Version of TikTok in Liangshan, China. Each village is defined as a cluster managed by a village doctor with 20 adults possessing mobile phones randomly selected from different families as participants, totaling 200 villages. Clusters are randomized (1:1:1) to the Control without mobile-based knowledge dissemination, Intervention A with standardized compensation to the village doctors, or Intervention B with performance-based compensation to the village doctors. The intervention groups will receive biweekly messages containing HIV-related educational modules. Data will be collected at baseline and 6-, 12-, and 18-month periods for outcome measurements. The primary outcomes of the study are HIV-related knowledge improvement and the effectiveness of village doctor targeted incentive policies. The secondary outcomes include secondary knowledge transmission, behavioral changes, health outcomes, social factors, and study design’s acceptability and reproducibility. These outcomes will be explored via various qualitative and quantitative means.

Discussion

The findings will provide insights into the effectiveness, generalizability, and challenges of the mobile-based HIV prevention intervention for the population living in rural communities with low education levels and will guide the development of similar models in other low-income and culturally isolated regions.

Trial registration

ClinicalTrial.gov: NCT05015062; Registered on June 6, 2022.

Evolutionary characteristics and immune mutation of hepatitis C virus genotype 1b among intravenous drug users in mainland, China

China is one of the countries with the heaviest burden of hepatitis C virus (HCV) worldwide, especially subtype 1b. To better control hepatitis C, insights into the characteristics of dynamic spread and genomic mutations are urgently needed. We retrieved sequences of HCV-1b NS5B among intravenous drug users (IDUs) and general people (Non-IDUs) in China from 2000 to 2011 in NCBI. Bayesian phylogenetic and phylogeographic analyses were used to evaluate the transmission dynamics of HCV-1b. Non-synonymous substitutions were detected to illustrate immune adaptation. Evolutionary history demonstrated that HCV-1b effective population size experienced a sharp increase in 1990. HCV-1b sequences among IDUs had a higher estimated evolutionary rate (5.7185 × 10^-3  substitutions/site/year) than overall (7.7332 × 10^-4 ). 105/136 (77.2%) of HCV-1b sequences clustered into 38 networks. The average non-synonymous HCV-1b immune epitopes among IDUs were 0.211, higher than non-IDUs, especially in the HLA-A*02 molecular recognition region. All of these posed significant challenges for the prevention and treatment of HCV. Heterogeneity and genetic linkages of HCV-1b suggest that evolutionary surveillance of HCV in cities in east-central China and among IDUs could not be neglected.

Independent epidemic patterns of HIV-1 CRF01_AE lineages driven by mobile population in Shenzhen, an immigrant city of China

Shenzhen, a city with &gt;12 million migrant population, may play a key role in the spread of human immunodeficiency virus (HIV)-1 in China. The transmission dynamics of CRF01_AE, a predominant subtype in Shenzhen, is a good model to characterize the impact of human mobility on HIV-1 epidemic locally and nationally. We used phylodynamic and phylogeographic methods to estimate the viral transmission dynamics and migration trajectory of variable lineages based on 1,423 CRF01_AE sequences in Shenzhen sampled between 2006 and 2015. Eleven lineages of CRF01_AE were detected in Shenzhen. Of those, four main lineages originated during the 1990s. Their basic viral reproduction number (R0) ranged 1.96–3.92. The effective viral reproduction number (Re) of two lineages prevalent among heterosexuals/people who inject drugs had reduced &lt;1 at the end of sampling, and the main sources were the intra-provincial immigrants (72 per cent) for one and local residents of Shenzhen (91 per cent) for another. Within two lineages among men who have sex with men (MSM), Re had been above or close to 1 at the end of sampling, and the immigrants from Jiangxi/Shaanxi and Hubei as sources accounted for 93 per cent and 68 per cent of all viral migration events, respectively. Moreover, no obvious recipients were found throughout the viral migration history for any lineage. Our findings demonstrate that HIV epidemic is declining in Shenzhen, which coincided with the initiation of the interventions during the 2000s. However, the obvious differences of the epidemic patterns between lineages emphasize the importance of further targeting interventions and continued molecular tracing, focusing on high-risk transmission sources among MSM.

The Epidemiological Analysis of HIV/AIDS Patients: Sexually Transmitted Diseases Department VS. Other Departments in A General Hospital of Shanghai, China

BACKGROUND

Hospital is an important place for HIV/AIDS screening, and a general hospital is composed of multiple departments. Different departments have different levels of understanding of HIV/AIDS, especially the sexually transmitted diseases (STD) department is the main place for HIV/AIDS screening.

OBJECTIVE

The study aims to validate the common knowledge that the STD department is an important place for HIV/AIDS screening by comparing the epidemiological characteristics of HIV/AIDS patients in the STD department and other departments in Tongji Hospital, which can provide a theoretical basis for the precise and differentiated control of HIV/AIDS.

METHODS

A total of 283,525 HIV screening cases were analyzed from January 1st 2006 to December 31st 2018 in the STD department and other departments. The epidemiological data of 226 HIV/AIDS cases were retrospectively analyzed.

RESULTS

Firstly, the incidence of HIV/AIDS in the population served by Tongji Hospital was higher than that in Shanghai and China. Secondly, the positive rate of HIV screening test in the STD department was ten times higher than that of other departments. Thirdly, the social-demographic characteristics of HIV/AIDS patients in the STD department were different from those in other departments. Fourthly, there were differences in age, education, marital status and number of sex partners between men who have sex with men (MSM) and men who have sex with women (MSW). Fifthly, there was no difference except age in social-demographic characteristics of MSM between the STD department and other departments. Sixthly, compared with other departments, the majority of HIV/AIDS patients in the STD department were MSM. Seventhly, syphilis and HIV co-infection were not statistically significant in HIV/AIDS patients between the STD department and other departments.

CONCLUSION

Firstly, the significantly higher positive rate of an HIV screening test in the STD department emphasizes its importance as a place for screening HIV/AIDS patients. Secondly, HIV/AIDS patients diagnosed in the general hospital were mainly transmitted by sexual contact, and MSM accounted for the most part of these patients. More attention should be paid to screen outpatients, especially in the STD department and young men.

Survey of Pretreatment HIV Drug Resistance and Genetic Transmission Network Analysis Among HIV Patients in a High Drug-Use Area of Southwest China

Background: Pretreatment drug resistance (PDR) poses an increasing threat to the success of antiretroviral treatment (ART) programs in China. We aimed to conduct a survey of PDR among HIV patients in an area in Southwest China with extensive drug trafficking.

Methods: Consecutive cross-sectional surveys were conducted in Liangshan Prefecture of Sichuan Province from 2009 to 2018 based on the WHO-recommended method. PDR was identified by testing pol region sequences with the Stanford HIVdb algorithm (version 7.0). PDR prevalence and related factors were assessed by multivariable logistic regression. The transmission of HIV drug resistance was analyzed using a genetic transmission network.

Results: HIV-1 pol genes from 1889 patients were successfully amplified. The distribution of HIV-1 genotypes was as follows: CRF07_BC (94.0%), CRF08_BC (2.3%), CRF01_AE (2.0%) and others (1.4%). Of the participants, 6.9% (95% CI: 4.1-8.1%) had pretreatment resistance to 12 antiretroviral drugs recommended by the WHO, and nucleoside reverse transcriptase inhibitor (NRTI), non-nucleoside reverse transcriptase inhibitor (NNRTI) and protease inhibitors (PI) resistance were identified among 1.4% (95% CI: 0.7-3.4%), 5.8% (95% CI: 1.2-8.7%) and 0.4% (95% CI: 0.1-3.0%) of the patients, respectively. In the multivariate logistic model, the prevalence of PDR was 1.52-fold higher among intravenous drug users (IDUs) than among patients infected by heterosexual transmission (95% CI: 1.07-2.38; P=0.049), and the prevalence of PDR among patients diagnosed from 2017-2018 was 2.03-fold higher than that among patients diagnosed from 2009-2016 (95% CI: 1.18-5.76; P=0.018). A total of 26 clusters containing PDR and a rapidly growing drug resistance-related cluster containing the E138Q and V179D mutations were identified by genetic transmission network analysis.

Conclusion: The results show a moderate overall level of PDR prevalence and rapidly growing drug resistance over time. Preventive intervention should be focused on controlling the HIV epidemic among drug users, and surveillance is urgently needed to monitor the trend of PDR.

High-risk behaviors and their association with awareness of HIV status among participants of a large-scale prevention intervention in Athens, Greece

Background

Aristotle was a seek-test-treat intervention during an outbreak of human immunodeficiency virus (HIV) infection among people who inject drugs (PWID) in Athens, Greece that started in 2011. The aims of this analysis were: (1) to study changes of drug injection-related and sexual behaviors over the course of Aristotle; and (2) to compare the likelihood of risky behaviors among PWID who were aware and unaware of their HIV status.

Methods

Aristotle (2012–2013) involved five successive respondent-driven sampling rounds of approximately 1400 PWID each; eligible PWID could participate in multiple rounds. Participants were interviewed using a questionnaire, were tested for HIV, and were classified as HIV-positive aware of their status (AHS), HIV-positive unaware of their status (UHS), and HIV-negative. Piecewise linear generalized estimating equation models were used to regress repeatedly measured binary outcomes (high-risk behaviors) against covariates.

Results

Aristotle recruited 3320 PWID (84.5% males, median age 34.2 years). Overall, 7110 interviews and blood samples were collected. The proportion of HIV-positive first-time participants who were aware of their HIV infection increased from 21.8% in round A to 36.4% in the last round. The odds of dividing drugs at least half of the time in the past 12 months with a syringe someone else had already used fell from round A to B by 90% [Odds Ratio (OR) (95% Confidence Interval-CI): 0.10 (0.04, 0.23)] among AHS and by 63% among UHS [OR (95% CI): 0.37 (0.19, 0.72)]. This drop was significantly larger (p = 0.02) among AHS. There were also decreases in frequency of injection and in receptive syringe sharing in the past 12 months but they were not significantly different between AHS (66 and 47%, respectively) and UHS (63 and 33%, respectively). Condom use increased only among male AHS from round B to the last round [OR (95% CI): 1.24 (1.01, 1.52)].

Conclusions

The prevalence of risky behaviors related to drug injection decreased in the context of Aristotle. Knowledge of HIV infection was associated with safer drug injection-related behaviors among PWID. This highlights the need for comprehensive interventions that scale-up HIV testing and help PWID become aware of their HIV status.

Interventions to improve the HIV continuum of care in China

PURPOSE OF REVIEW

To describe HIV epidemic and interventions for improving HIV continuum of care in China.

RECENT FINDINGS

The reported HIV epidemic has been continuously increasing, partially due to the expansion of active HIV testing campaign. Public health intervention programs have been effective in containing HIV spread among former plasma donors and people who inject drugs (PWID), but more infections occur among heterosexual men and women and young men who have sex with men. Of 1.25 million Chinese people are living with HIV, one-third do not know their status. About two-thirds of diagnosed individuals have used antiretroviral therapy (ART) and two-thirds of those on ART have achieved viral suppression, but some risk groups such as PWID have lower rates. The national free ART program has reduced adult and pediatric mortality and reduced heterosexual transmission. China faces great challenges to reduce HIV sexual transmission, improve the HIV continuum of care, and close the gaps to the UNAIDS Three "90" Targets.

Risky Sexual Behavior Among Individuals Receiving Buprenorphine/Naloxone Opiate Dependency Treatment: HIV Prevention Trials Network (HPTN) 058

INTRODUCTION

Understanding the role of opiate dependency treatment in risky sexual behavior could help optimize interventions for people who inject drugs (PWID).

OBJECTIVES

We evaluated whether long-term medication-assisted treatment (LT-MAT) of opiate dependency with buprenorphine/naloxone influenced risky sexual behavior among HIV-uninfected PWID and identified predictors of risky sexual behavior.

METHODS

We used data from HPTN 058, a randomized controlled trial of LT-MAT vs. short-term medication-assisted treatment among PWID in China and Thailand. We evaluated associations between randomized opiate dependency treatment group and self-reported risky sexual behaviors within the past month: condomless sex with primary partner, condomless sex with nonprimary partner, multiple partners, and more than 3 sexual acts. We used generalized estimating equations to conduct intention-to-treat, as-treated, and exploratory analyses of these associations.

RESULTS

Of 1250 participants included in the analysis, 92% were male, with median age of 34 years (interquartile range 28-39). At baseline, referring to the past month, 36% of participants reported condomless sex with primary partner, 4% reported condomless sex with nonprimary partner, 6% reported multiple sex partners, and 30% reported more than 3 sexual acts. Risky sexual behaviors did not differ significantly between treatment groups at any point. Significant predictors (P < 0.05) of condomless sex with nonprimary partner were history of incarceration and noninjection drug use. Number of needle-sharing partners, noninjection drug use, and higher income were predictors for multiple sexual partners.

CONCLUSIONS

LT-MAT did not significantly modify risky sexual behavior among HIV-uninfected PWID. Interventions that reduce sexual risk should target PWID with history of incarceration, alcohol use, and needle sharing.

DOES IT WORK? -a randomized controlled trial to test the efficacy of HCV and HIV-related education on drug users in MMT, China

BACKGROUND

HCV (Hepatitis C virus) is a prevalent chronic disease with potentially deadly consequences, especially for drug users. However, there are no special HCV or HIV (human immunodeficiency virus)-related intervention programs that are tailored for drug users in China; to fill this gap, the purpose of this study was to explore HCV and HIV-related knowledge among drug users in MMT (methadone maintenance treatment) sites of China and to investigate the effectiveness of HCV and HIV-related education for improving the knowledge of IDUs (injection drug users) and their awareness of infection.

METHODS

The study was a randomized cluster controlled trial that compared a usual care group to a usual care plus HCV/HIV-REP (HCV/HIV-Reduction Education Program) group with a 24-week follow-up. The self-designed questionnaires, the HCV- and HIV-related knowledge questionnaire and the HIV/HCV infection awareness questionnaire, were used to collect the data. Four MMT clinics were selected for this project; two MMT clinics were randomly assigned to the research group, with subjects receiving their usual care plus HCV/HIV-REP, and the remaining two MMT clinics were the control group, with subjects receiving their usual care over 12 weeks. Sixty patients were recruited from each MMT clinic. A total of 240 patients were recruited. Follow-up studies were conducted at the end of the 12th week and the 24th week after the intervention.

RESULTS

At baseline, the mean score (out of 20 possible correct answers) for HCV knowledge among the patients in the group receiving the intervention was 6.51 (SD = 3.5), and it was 20.57 (SD = 6.54) for HIV knowledge (out of 45 correct answers) and 8.35 (SD = 2.8) for HIV/HCV infection awareness (out of 20 correct answers). At the 12-week and 24-week follow-up assessments, the research group showed a greater increase in HCV-/HIV-related knowledge (group × time effect, F = 37.444/11.281, P < 0.05) but no difference in their HIV/HCV infection awareness (group × time effect, F = 2.056, P > 0.05).

CONCLUSION

An MMT-based HCV/HIV intervention program could be used to improve patient knowledge of HCV and HIV prevention, but more effort should be devoted to HIV/HCV infection awareness.

TRIAL REGISTRATION

Protocols for this study were approved by institution review board (IRB) of Shanghai Mental Health Center (IRB:2009036), and registered in U.S national institutes of health (http://www.clinicaltrials.gov, NCT01647191 ). Registered 23 July 2012.

Mixed methods to explore factors associated with the decline of patients in the methadone maintenance treatment program in Shanghai, China

Background

This study was to characterize the Methadone Maintenance Treatment (MMT) in Shanghai, China, and to explore factors associated with the decline of patients in MMT during 2005–2016.

Methods

Both qualitative and quantitative methods were used in this study. Based on the data from Shanghai Centers for Disease Control (CDC), we described the changes in the number of patients who received MMT, and new enrollment each year from 2005 to 2016. Focus groups were conducted with 22 patients, and in-depth interviews were conducted with 9 service providers.

Results

Quantitative data demonstrate that the number of new enrollment began to decline in 2009, and the number of patients receiving MMT began to decline in 2012. The main reasons for dropout include (1) discontinuing medication due to unknown reasons (25%), (2) criminal activities other than drug-related crimes (20%), (3) relapse to heroin use (16%), and (4) physical disease (10%). Qualitative assessment results indicate that the major reasons for the decline of patients in MMT are as follows: (1) the increase of Amphetamine-type stimulants (ATS) use in recent years, (2) limited knowledge about MMT in both patients and MMT staff, (3) complicated enrollment criteria, and (4) discrimination against drug use.

Conclusion

Various reasons to explain the decline of patients in MMT in Shanghai, China, were identified. Government agencies, service providers, and other stakeholders need to work together and overcome identified barriers to support MMT programs in China.

Causes and Consequences of Drug Abuse: A Comparison Between Synthetic Drug and Heroin Users in Urban China

This article examined the differences in causes and health consequences between synthetic drug and heroin abuse in urban China. Two-group comparisons were conducted to quantify differences in individual characteristics, causes of drug use, and HIV/STI risky sexual behavior between synthetic drug and heroin users; logistic regressions were employed to assess the net effect of synthetic drug use on risky sexual behavior. Results revealed that causes of synthetic drug use differed from those of heroin use; a combination of the knowledge gap concerning the harmful impact of synthetic drugs and the lesser punishment for their use appeared a main reason behind the shift from heroin to synthetic drugs; and synthetic drug use was a significant and powerful risk factor for HIV/STI risky sexual behavior. Educational and behavioral interventions are urgently needed to prevent the initiation of synthetic drug use among users to reduce their HIV/STI risky sexual behavior.

Effect of community-based extension clinics of methadone maintenance therapy for opiate-dependent clients: A prospective cohort study in Dehong Prefecture, Yunnan Province of China

Methadone maintenance therapy (MMT) is effective in treatment of opiate dependents. However, there is a gap between the coverage of standard MMT clinics and the need of opiate dependents. Establishment of extension clinics of methadone maintenance therapy (EMMT) will increase the coverage and improve MMT accessibility. We implemented a prospective cohort study to understand the effects of establishment of community-based EMMT clinics comparing with MMT clinics in Yunnan Province.A total of 462 opiate-dependent clients were interviewed from the community-based EMMT clinics and standard MMT clinics located in 5 counties of Mangshi, Ruili, Longchuan, Yingjiang, and Lianghe in Yunnan Province. The information on the demographic characteristics, drug risk behaviors, quality of life (QOL), and urine testing results for morphine of the clients was collected and compared between the EMMT and MMT clinics. A survival analysis method was utilized to know the retention situation of the newly enrolled clients with Kaplan-Meier method during 9 months treatment.Among the EMMT clients, 96.9% were male; 31.4% were Han; 61.4% were married; 39.0% had primary school education; 95.5% lived with their family or relatives; 96.9% who arrived the clinic less than 15 min; 52.9% had used drugs for more than 10 years; and 16.7% injected drug. After 9 months therapy, there was no difference in the changes of life quality such as physical and psychological features, social relationships, environmental function, and total QOL and well-being between those of EMMT and MMT clinics. The positive detection rate of urine-morphine testing among newly enrolled clients of EMMT clinics decreased as the period of treatment lengthened. The average time of retention for newly enrolled EMMT clients who are still receiving the treatment was 175 days. And the average time from initiations to drop-out of treatment for newly enrolled EMMT clients was 122 days. The 9-month retention rates of the clients were 52.1% and 60.9% at EMMT and MMT clinics, respectively.The effect on EMMT retention was the same as that of MMT. Establishment of EMMT clinics was an effective strategy to expand the coverage of MMT and increase the retention of opiate dependents in the rural areas of the counties.

Hepatitis C infection, related services, and barriers to HCV treatment among drug users in methadone maintenance treatment (MMT) clinics in Shanghai, China

Background

The purpose of this study was to document the prevalence of hepatitis C among MMT patients, hepatitis C virus (HCV) knowledge of patients and MMT staff members, and the barriers preventing them from receiving or delivering HCV-related services in MMT clinics of China.

Methods

Data were collected from 240 MMT patients and 58 staff members in Shanghai MMT clinics. Structured questionnaires (HCV Knowledge Scale and Alcohol Use Disorders Identification Test) and several self-developed questionnaires were used to assess (1) patient and staff HCV knowledge, (2) attitudes toward HCV-related services in MMT clinics, and (3) what type of HCV-related services the staff members have provided in their routine work. The HCV test results were based on the patients’ medical records.

Results

The HCV seropositive rate was high (70%), and both patients and staff had limited HCV knowledge. The mean score of patient HCV knowledge was 6.8 out of 20 (SD = 3.7), whereas the mean score of staff HCV knowledge was 10.9 out of 20 (SD = 3.1). For HCV-positive patients, only 13.7% had accessed HCV medical treatment. Barriers included the cost of medical treatment, lack of HCV knowledge, lack of professional training for patients to receive HCV-related services from individuals or MMT clinics, and lack of an adequate policy-making system.

Conclusions

HCV infection remains an important problem among MMT patients in China. Barriers to HCV-related services are attributable to individual, clinical, and policy-related factors. This study may provide evidence-based information for future work to optimize the resources of MMT clinics.

Trial registration

ClinicalTrials.gov NCT01647191. Registered 17 April 2012.

The synergistic effect of dual use of amphetamine-type stimulants and ketamine on drug-induced psychotic symptoms in Chinese synthetic drug users

The use of amphetamine-type stimulants (ATS) and ketamine is of particular clinical concern because of its associated psychotic symptoms. In Chinese clinical practice, ATS and ketamine are commonly used simultaneously, but very few studies have reported the symptom profile of users who use both drugs. This study determined whether the combined use of ATS and ketamine is associated with more psychotic symptoms than either ATS or ketamine alone. According to drug use characteristics, 375 Chinese synthetic drug users were categorized into 2 pairs of comparison groups: ATS-only (n=125) vs. ATS-mainly (ATS most of the time and ketamine sometimes, n=150) and ketamine-only (n=38) vs. ketamine-mainly (ketamine most of the time and ATS sometimes, n=62). We used the Chinese Brief Psychiatric Rating Scale (BPRS) to assess these patients’ psychotic symptoms. ATS-mainly group had more anxiety/depression and anergia symptoms than ATS-only group (p<0.001), and ketamine-mainly group had more thinking-disorder, activity and hostility-suspicion symptoms than ketamine-only group (p≤0.001). These findings indicate that ATS may exacerbate the thinking-disorders, activity and hostility-suspicion symptoms of ketamine users, and ketamine may exacerbate anxiety/depression and anergia symptoms of ATS users.

The HIV/AIDS epidemic among young people in China between 2005 and 2012: results of a spatial temporal analysis

OBJECTIVES

Despite a recent increase in the HIV/AIDS epidemic among young people in China, youth-specific HIV data are limited.

METHODS

In total, 56 621 individuals with HIV/AIDS, aged 15-24 years, registered in the Case Reporting System of China between 2005 and 2012 and having complete spatial information were included in the present analysis. Spatial autocorrelation (general and local) and space-time scanning were performed using the ArcGIS 10.2 and SaTScan 9.3 software, respectively.

RESULTS

During 2005-2012, the number of reported HIV/AIDS cases and the proportion of HIV cases increased while the proportion of AIDS cases decreased. Sexual contact became the predominant route of transmission in later years. Spatial analysis showed marked geographical variations in HIV infection among young people throughout China during 2005-2012. The number of new hotspots increased over time. They were mainly localized to southeastern coastal areas, southwestern frontier provinces or autonomous regions (of Guangxi, Yunnan and Sichuan) and Beijing municipality. Later these hotspots disappeared and new hotspots were found in the northeast of the country. Significant clusters of HIV-positive cases were identified in three different time periods, which indicated high HIV transmission among young Chinese people in the recent past. The risk of HIV infection was highest in the first cluster (2009-2012; this cluster was the largest in size) covering the provinces of Guizhou and Yunnan, the Chongqing municipality, Guangxi, and the province of Sichuan. The second cluster (2010-2012) was mostly located in Shanghai, South Jiangsu, Zhejiang and South Anhui, while the third cluster (2010-2012) was located in Beijing and Tianjin.

CONCLUSIONS

Target-specific comprehensive behavioural interventions are urgently needed to contain the HIV epidemic among young people.

Epidemiology of Drug Use and HIV-Related Risk Behaviors among People Who Inject Drugs in Mwanza, Tanzania

Heroin trafficking and consumption has increased steadily over the past decade in Tanzania, but limited information regarding HIV and drug use exists for the city of Mwanza. Our study investigates the epidemiology of drug use, and HIV risk behaviors among drug users in the northwestern city of Mwanza. Using a combination of targeted sampling and participant referral, we recruited 480 participants in Mwanza between June and August 2014. The sample was 92% male. Seventy-nine (16.4%) participants reported injecting heroin, while 434 (90.4%) reported smoking heroin. Unstable housing and cohabitation status were the only socioeconomic characteristics significantly associated with heroin injection. More than half of heroin injectors left syringes in common locations, and half reported sharing needles and syringes. Other risk behaviors such as lack of condom use during sex, and the use of illicit drugs during sex was widely reported as well. Among the study sample, there was poor awareness of health risks posed by needle/syringe sharing and drug use. Our results show that heroin use and HIV risk related behaviors are pressing problems that should not be ignored in Mwanza. Harm reduction programs are urgently needed in this population.

Compulsory treatment of drug users in Asia: designed to torture?

PURPOSE

- Injecting drug use is a global concern, with an estimated 16 million people who inject drugs (PWIDs) in over 148 countries. A number of Asian countries detain PWIDs for compulsory treatment. The paper aims to discuss this issue.

DESIGN/METHODOLOGY/APPROACH

- The authors reviewed the literature on compulsory drug treatment in seven Asian countries.

FINDINGS

- The authors identified 1,269 closed settings which held over 600,000 drug users in eight countries. The average detainee was aged from 20 to 30 years and was predominantly male. HIV risk behaviour continued in detention in some countries. In most countries treatment comprised physical labour, military drills. Methadone maintenance treatment and antiretroviral therapy were rarely available. No data were located to show detention in a closed setting treated drug dependency. Issues of concern were; no due legal process for the detention of drug users, lack of evidence-based drug treatment, lack of HIV prevention and treatment, abusive conditions, forced labour and exercise, arbitrary exit procedures and very high relapse rates.

RESEARCH LIMITATIONS/IMPLICATIONS

- The review of compulsory treatment of drug users failed to find any evaluation of effective drug treatment for detainees. Instead serious breaches in human rights conditions were evident. Prominent international organisations have called for the compulsory treatment of drug users to cease.

PRACTICAL IMPLICATIONS

- Many countries are spending vast amounts of funding on ineffective treatments for drug users.

SOCIAL IMPLICATIONS

- Funding should be directed to community-based drug treatments that have been shown to work.

ORIGINALITY/VALUE

- This is the largest review of compulsory treatment of drug users to date.

Trends of HIV subtypes and phylogenetic dynamics among young men who have sex with men in China, 2009-2014

To investigate the origins of HIV transmission and phylogenetic dynamics among men who have sex with men (MSM), a total of 1205 newly diagnosed HIV-infected 16-25 year-olds were recruited in 13 provinces across China between 2009 and 2014. Based on phylogenetic analyses of partial pol sequences, HIV-1 subtypes including CRF01_AE (45.3%), CRF07_BC (37.8%), subtype B (6.1%), and B' (3.7%), as well as some other recombinants (7.1%) were identified. In addition to two distinct CRF01_AE clusters [cluster 4 (33.7%, 406/1205) and cluster 5 (7.1%, 85/1205)], we identified a new CRF07_BC cluster (cluster 1) (36.0%, 434/1205), which entered Chinese MSMs in 2004, and had been rapidly spreading since about 2004, which indicating the third wave of the HIV epidemic among the population. Moreover, two new clusters of CRF_01B recombinants were found in this study. The complexities of HIV subtypes and recombinants strongly supports the necessity for a comprehensive study about risk behaviors and their relationship with increasing HIV epidemic subtypes among the MSM group. Implementation and evaluation of comprehensive harm reduction strategies in Chinese MSM are urgently needed.

Methadone maintenance treatment programme reduces criminal activity and improves social well-being of drug users in China: a systematic review and meta-analysis

OBJECTIVE

Methadone maintenance treatment (MMT) has been implemented in China since 2004 and has expanded into a nationwide programme. This study aims to evaluate changes in social functioning, family relations and drug-related criminal behaviour among MMT clients in China.

DESIGN

Systematic review and meta-analysis.

METHODS

Both English and Chinese literature databases, including PubMed, Chongqing VIP Chinese Science and Technology Journals Database (CQVIP), China National Knowledge Infrastructure (CNKI) and Wanfang Data, were comprehensively searched over the period 2004-2014 for studied indicators. Study selection, quality assessment and data extraction were conducted according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) Statement. Meta-analyses were conducted using Comprehensive Meta-Analysis Biostat software.

RESULTS

Thirty-eight articles were included in this review (1 in English and 37 in Chinese). The self-reported arrest rate decreased from 13.1% (95% CI 9.1% to 18.5%) at baseline to 3.4% (95% CI 1.5% to 7.7%) and 4.3% (95% CI 1.6% to 11.4%) after 6 and 12 months of MMT intervention, respectively. The rate of drug selling decreased from 7.6% (95% CI 3.8% to 14.8%) at baseline to 1.9% (95% CI 0.6% to 6.2%) and 3.0% (95% CI 1.0% to 8.9%) after 6 and 12 months of intervention, respectively. Similarly, the rates of selling sex for drugs and drug-related crime decreased from 5.3% (95% CI 2.4% to 11.1%) and 9.9% (95% CI 6.8% to 14.2%) at baseline to 1.1% (95% CI 0.5% to 2.3%) and 3.4% (95% CI 2.5% to 4.5%) at 6 months, then to 0.8% (95% CI 0.3% to 1.9%) and 3.4% (95% CI 0.8% to 13.1%) at 12 months after treatment initiation, respectively. In contrast, the rate of employment of clients and the proportion of clients having a good relationship with their family increased substantially from 26.4% (95% CI 22.9% to 30.1%) and 37.9% (95% CI 32.0% to 44.2%) to 41.6% (95% CI 36.6% to 48.0%) and 59.6% (95% CI 48.1% to 70.2%) at 6 months, then to 59.8% (95% CI 52.4% to 66.8%) and 75.0% (95% CI 69.0% to 80.2%) at 12 months after treatment initiation, respectively.

CONCLUSIONS

MMT has significantly reduced criminal activity, and improved employment rate and social well-being, of clients of the MMT programme. MMT is an effective measure to help drug users to resume societal and familial functions in China.

Retention and its predictors among methadone maintenance treatment clients in China: a six-year cohort study

BACKGROUND

To investigate factors associated with retention among the first cohort of drug users attending methadone maintenance treatment (MMT) clinics in China.

METHODS

A six-year cohort of 1511 drug users was enrolled in the first 8 MMT clinics in China in 2004 and followed between March, 2004 and December, 2010. Six-year retention rates were calculated and compared by methadone dosage, clinic location, and length of follow-up. Factors associated with retention were evaluated using Cox proportional hazard regression models.

RESULTS

The overall retention rate over 6-year was 35.7%. Highest drop-out occurred within the first 12 months of treatment. The retention rates for the 6-year by low (≤ 30 mg/day), medium (31-60 mg/day), and high (>60 mg/day) methadone dosage groups were 20.8%, 34.8% and 53.2%, respectively (p < 0.001). The highest 6-year retention rate among eight clinics was 43.8%, while the lowest one was 17.7% (p < 0.001). The results from Cox proportional hazard models indicate that clients having >30 mg daily methadone dosage (p < 0.001), having relatives receiving MMT (p = 0.027), and having >10% urine morphine positive result (p < 0.001) were more likely to be retained in MMT over the six-year period. It has also found that drug injection (p = 0.005) and needle sharing (p < 0.0001) were significantly associated with better retention.

CONCLUSIONS

Health workers should adjust individuals' methadone dosages as a method to prevent early treatment termination. Further studies are needed to explore the impact of severity of opiate addiction on long-term retention of MMT clients. Careful assessment of drug users upon MMT enrollment may be helpful for providing additional care to clients.

Rural-to-urban migrants are at high risk of sexually transmitted and viral hepatitis infections in China: a systematic review and meta-analysis

Background

Rapid economic development in urban China has led to a mass migration of surplus rural residents into urban areas for better employment opportunities. This study aims to identify prevalence levels and risks of sexually transmitted infections (STIs) and hepatitis among the rural-to-urban migrant population in China.

Methods

Chinese and English literature databases were searched for studies reporting prevalence of HIV, STIs and viral hepatitis among rural-to-urban migrants in China between 1990 and 2013. The estimates were summarised through a systematic review and meta-analysis. The risks of infection were compared between migrants and the general Chinese population.

Results

We identified a total of 411 eligible studies. The prevalence of HIV, syphilis, gonorrhea, genital warts and HCV among migrants were 0.23% (0.20-0.27%), 0.69% (0.57-0.84%), 2.18% (1.30-3.64%), 1.54% (0.70-3.36%) and 0.45% (0.31-3.65%), representing 4.0 (3.1-5.2), 1.9 (1.1-3.0), 13.6 (5.8-32.1), 38.5 (15.7-94.5) and 3.8 (1.9-7.3) higher odds of infection than among the general population. Construction workers, long-distance truck drivers and migrant women through marriage were migrant subgroups that were highly susceptible to STIs and hepatitis. HIV prevalence among migrant pregnant women (0.10%, 0.02-0.49%) was significantly higher than that of pregnant women in the general Chinese population (OR = 7.7, 3.4-17.4). However, no significant differences were observed in STIs and hepatitis between overall female sex workers (FSWs), men who have sex with men (MSM) and drug users (DUs), and the corresponding subgroups with a migratory background.

Conclusions

Rural-to-urban migrants have a higher risk of STIs and hepatitis than the general Chinese population, but a migratory background does not increase the infection risks of STIs and hepatitis in FSWs, MSM and DUs.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2334-14-490) contains supplementary material, which is available to authorized users.

Do community-based strategies reduce HIV risk among people who inject drugs in China? A quasi-experimental study in Yunnan and Guangxi provinces

Background

HIV transmission among people who inject drugs (PWID) is high in Yunnan and Guangxi provinces in southwest China. To address this epidemic, Population Services International (PSI) and four cooperating agencies implemented a comprehensive harm reduction model delivered through community-based drop-incenters (DiC) and peer-led outreach to reduce HIV risk among PWID.

Methods

We used 2012 behavioral survey data to evaluate the effectiveness of this model for achieving changes in HIV risk, including never sharing needles or syringes, always keeping a clean needle on hand, HIV testing and counseling (HTC), and consistent condom use. We used respondent-driven sampling to recruit respondents. We then used coarsened exact matching (CEM) to match respondents during analysis to improve estimation of the effects of exposure to both DiC and outreach, only DiC, and only outreach, modeled using multivariable logistic regression.

Results

We found a significant relationship between participating in both peer-led DiC-based activities and outreach and having a new needle on hand (odds ratio (OR) 1.53, p < .05) and consistent condom use (OR 3.31, p < .001). We also found a significant relationship between exposure to DiC activities and outreach and HIV testing in Kunming (OR 2.92, p < .01) and exposure to peer-led outreach and HIV testing through referrals in Gejiu, Nanning, and Luzhai (OR 3.63, p < .05).

Conclusions

A comprehensive harm reduction model delivered through peer-led and community-based strategies reduced HIV risk among PWID in China. Both DiC activities and outreach were effective in providing PWID behavior change communications (BCC) and HTC. HTC is best offered in settings like DiCs, where there is privacy for testing and receiving results. Outreach coverage was low, especially in Guangxi province where the implementation model required building the technical capacity of government partners and grassroot organizations. Outreach appears to be most effective for referring PWID into HTC, especially when DiC-based HTC is not available and increasing awareness of DiCs where PWID can receive more intensive BCC interventions.

HIV prevalence trends, risky behaviours, and governmental and community responses to the epidemic among men who have sex with men in China

Purpose of Review. Numerous studies reported the rapid spread of HIV/AIDS epidemic among men who have sex with men (MSM) in China. This paper aims to investigate the overall epidemic trend and associated high-risk behaviours among Chinese MSM and to explore the governmental and community responses to the epidemic. Recent Findings. HIV prevalence among Chinese MSM increased rapidly in all Chinese regions in the past decade and disproportionally affected the Southwest China. In addition to the high-risk homosexual behaviours, overlapping bisexual, commercial, and drug use behaviours are commonly observed among Chinese MSM. The Chinese government has significantly expanded the surveillance efforts among MSM over the past decade. Community responses against HIV have been substantially strengthened with the support of international aid. However, lack of enabling legal and financial environment undermines the role of community-based organisations (CBOs) in HIV surveillance and prevention. Conclusion. HIV continues to spread rapidly among MSM in China. The hidden nature of MSM and the overlapping homosexual, bisexual, and commercial behaviours remain a challenge for HIV prevention among MSM. Strong collaboration between the government and CBOs and innovative intervention approaches are essential for effective HIV surveillance and prevention among MSM in China.

Exploring stakeholder perceptions of facilitators and barriers to using needle exchange programs in Yunnan Province, China

Injection drug use is an ongoing urban health crisis in China and one of the largest drivers of the transmission of HIV/AIDS. Sentinel surveillance sites in Yunnan province show upwards of 20% of injection drug users (IDUs) are HIV positive. Though the Ministry of Health has scaled-up needle exchange programs (NEPs), they have not received official government recognition nor have they been extensively evaluated to explore factors influencing their acceptability and feasibility. Using in-depth qualitative interviews conducted from February to July 2008 with 35 participants consisting of IDUs and other key stakeholders, we explored facilitators and barriers to accessing needle exchange programs in Kunming, the capital of Yunnan province. Content analysis was conducted to identify themes including attitudes toward NEPs and harm reduction, barriers to access, and suggestions for improvement. Themes that emerged included fears of breached confidentiality and police interference at the exchange sites and tensions between the public health and law enforcement perspective. Low levels of NEP-related knowledge and awareness were uniformly reported among interviewees. Suggestions to facilitate an increase in NEP acceptance included raising awareness of harm reduction and HIV more generally, offering services such as psychological counseling, job training and behavioral therapy at NEPs, and increasing communication between police, government, and public health officials. High rates of HIV infection among injection drug users in China have prompted rapid scale up of NEPs. Additional adaptations are necessary, however, to increase needle exchange use among injection drug users. This study finds that an urgent need to raise awareness of NEPs among policy makers and IDUs and act upon identified steps for developing social-structural interventions to create enabling environments that facilitate increased access to NEPs among injection drug users in Kunming.

The effects of different doses of ketamine on quality of normal ejaculated sperm

BACKGROUND

Ketamine, an injectable anesthetic in human and animal medicine, is also a recreational drug used by young adults. The aim of this study is to evaluate the effects of ketamine on membrane integrity, DNA fragmentation and sperm parameters in humans.

MATERIALS AND METHODS

This prospective study was conducted on 40 males with normal semen samples over one month (August 2012). Subjects were randomly allocated to four groups (Control and case I, II and III) whose semen samples were adjusted to different concentrations of ketamine (1, 3, 5 µL) for one hour. Sperm analysis was performed for routine parameters, motility and morphology. Evaluation of membrane integrity and DNA fragmentation was done by eosin-Y staining and the sperm chromatin dispersion (SCD) test, respectively. The results were analyzed by ANOVA and Tukey's tests. P≤0.05 was considered statistically significant.

RESULTS

Total sperm motility in all case groups were significantly lower compared with the control group. In case group III, progressive motility showed significant difference with case group II. After addition of ketamine, sperm had evidence of coiled tails in all case groups compared to the control group however this observation was not significant. Evaluation of membrane integrity showed the rate of necrospermia increased in all case groups. However, ketamine only significantly affected membrane integrity in case group III. SCD staining showed that in the control group nucleoids with medium halos (63.44 ± 1.2) were significantly different compared to the case groups I (15.44 ± 0.45), II (9.05±1.16) and III (10.55 ± 1.14), respectively. Between case groups, nucleoids with large and medium halos showed significant differences in case groups II and III compared with case group I. Nucleoids with medium halos were significantly different between case groups II and III.

CONCLUSION

Ketamine, through its effect on membrane integrity and DNA fragmentation, decreased sperm viability and caused abnormal sperm parameters in progressive motility.

Effect of Methadone Dose on Maintenance Treatment and Health Consequences Among Heroin Addicts in South China

A retrospective cross-sectional study was conducted with a convenience sample of 197 adults receiving methadone maintenance treatment in Kunming city, South China, in 2010. The aim of the study was to determine the association of methadone maintenance dose on a variety of treatment outcomes. Treatment modalities, the adverse reactions to methadone treatment, the physical and mental outcomes of the treatment, and risk behavior changes were assessed. Multilevel negative and logistic binomial regression analyses were carried out, which demonstrated that methadone maintenance dose in this sample was not associated with improved treatment adherence or with quality of life. We concluded that dose had a small, if negligible, influence on the changes in adverse effects of methadone. Further research in dose differences between the genders should be conducted.

Effectiveness of prize-based contingency management in a methadone maintenance program in China

BACKGROUND

Methadone maintenance treatment (MMT) has been successfully scaled up nationally in China. However, the program faces problems of poor attendance and high rates of continued drug use. We assessed whether a contingency management (CM) intervention implemented by MMT clinic staff could improve treatment attendance and drug abstinence.

METHODS

Eight MMT clinics in Guangdong province were randomly selected and divided into two groups. A total of 126 participants (55 in urban clinics and 71 in rural clinics) received CM during a 12-week trial, 120 participants (83 in urban clinics and 37 in rural clinics) received usual treatment (UT). Participants in the CM group had the opportunity to draw for prizes contingent on attending treatment daily and testing negative for morphine. Clinic- and individual-level outcomes were compared between the intervention and control groups.

RESULTS

The retention rate and negative urine testing rate were 14.2% (P=0.010) and 10.7% (P<0.001) higher in the CM group compared to the UT group, respectively. Compared with participants who received UT, CM participants missed on average 7.3 fewer (P=0.008) visits and were 1.91 (95% CI: 1.53-2.39) times more likely to submit a negative urine sample. All clinic- and individual- level effects of the intervention were observed at rural clinics, but the difference in retention rate between urban CM and UT clinics was not significant.

CONCLUSION

Although the frequency of monitoring and value of the incentives in this study was lower than in previous studies, the CM intervention significantly improved attendance and reduced drug use in China.

Evaluation of harm reduction programs on seroincidence of HIV, hepatitis B and C, and syphilis among intravenous drug users in southwest China

OBJECTIVE

The aim of this study was to evaluate the impact of a multifaceted harm reduction program by comparing seroincidence rates of HIV, hepatitis C virus (HCV), hepatitis B virus (HBV), and syphilis before and after implementation of harm reduction strategies among intravenous drug users (IDUs) in a drug-trafficking city in Southwest China.

DESIGN

This is a prospective cohort study with 24 months of follow-up.

METHODS

Two prospective cohorts (cohort 2002-2004 and cohort 2006-2008) were followed up every 6 months for seroconversions of HIV, HCV, and syphilis antibodies and HBV surface antigen.

RESULTS

After implementation of harm reduction strategies in Xichang city, Sichuan province, the HIV incidence rate among IDUs significantly dropped from 2.5 to 0.6 cases per 100 person-years. Subanalyses also indicated that the incidence rate of HBV significantly declined from 14.2 to 8.8 cases per 100 person-years. No significant changes in the seroincidence rates of HCV or syphilis were detected after implementation of IDU harm reduction strategies.

CONCLUSIONS

Harm reduction strategies may help reduce the high incidence of certain blood-borne infectious diseases and sexual transmitted diseases among high-risk IDUs in southwest China. Additional research is needed on the implementation and evaluation of harm reduction strategies in China.

Predictors of continued HIV-risk behaviors among drug users in methadone maintenance therapy program in China--a prospective study

BACKGROUND

To examine the predictors of continued drug- and sex-related HIV-risk behaviors among drug users in methadone maintenance therapy (MMT) programs in China.

METHODS

We followed a sample of 5,035 drug users enrolled for the first time in MMT programs at baseline, 6 months, and 12 months utilizing a longitudinal prospective study design. Drug users' HIV-risk behaviors, MMT characteristics, and drug use, were assessed at all three waves using a structured interview and HIV/HCV status was assessed at baseline and 12-month follow-up using biological specimens.

RESULTS

The point prevalence of HIV was 7.6% and 78.4% for HCV at baseline. Results of generalized linear mixed logistic regression models revealed that HIV-positive MMT clients were more likely to engage in drug injection (aOR = 1.70) and syringe sharing (aOR = 4.73). HCV-positive clients were more likely to inject drugs (aOR = 2.58), share syringes (aOR = 1.97), and have multiple sexual partners (aOR = 1.47). Adherence to MMT was the most significant predictor of reduced HIV-risk behaviors.

CONCLUSIONS

Our data confirmed the positive effects of MMT on HIV prevention and underscored the urgency for programs to reduce HIV risk in HIV- and HCV-positive clients. There is a pressing need to strengthen existing counseling services for HIV-positive drug users to reduce their drug-related risk behaviors and to provide counseling for HCV-positive drug users. Further studies are needed to explore interventions to address high dropout rates and low adherence among MMT clients.

Social science research on HIV in Vietnam: a critical review and future directions

Social science research can enhance the response to Vietnam's growing HIV epidemic by capturing the country's rapidly changing social and political context. The present paper reviews the published, peer-reviewed and English-language social science literature on HIV in Vietnam in order to identify critical theoretical and substantive gaps, while laying the groundwork for future research. We found four broad foci for work on the social context of HIV and AIDS in Vietnam: the cultural meanings and social relationships that shape Vietnam's HIV epidemic; stigma and discrimination; social inequality and structural violence as contributors to HIV risk; and, finally, how broader global and social systems shape Vietnam's HIV epidemic. We signal the particular need for additional research on the effects of the media on attitudes towards HIV and AIDS, on social movements, and on health systems, as well as on a number of other key areas. Work along these lines, in addition to more effective communication of policy-relevant findings to those responsible for the development and implementation of policies and programmes, will strengthen Vietnam's response to HIV and AIDS.

Trends and predictors in methadone maintenance treatment dropout in Shanghai, China: 2005-2011

BACKGROUND

The methadone maintenance treatment (MMT) program has been implemented in Shanghai since 2005. This study aims to portray the trend of MMT dropout and identify predictive factors that may influence dropout in Shanghai MMT clinics, which could assist in the intervention strategy development.

METHODS

A retrospective evaluation was used in the Shanghai component of the National MMT data management system between January 1, 2005 and December 31, 2011. The Cox model for recurrence events was employed to estimate hazard ratio (HR) predicting dropout during the follow-up period.

RESULTS

Of all 6169 participants, 63% dropped out of the program at least once (ranging from 0 to 10 times), and 74% of them did not return by the end of this study. The average monthly incidence rate of dropout was 4.4% with a range from 0 to 9.3%. Adjusted analyses demonstrated that the individuals with methadone tapering didn't have a greater probability of dropping out compared to those with stable dosage (HR = 1.07, 95% CI: 0.90-1.27). However, there was a higher dropout rate among younger individuals (<30 years vs. ≥50 years old; HR = 1.41, 95% CI: 1.16-1.71), among those who were less educated (HR = 1.48, 95% CI: 1.17-1.87), among those who shared needles with others (HR = 1.29, 95% CI: 1.06-1.58), among those whose urine tested positive for opiates (HR = 1.69, 95% CI: 1.51-1.89), and among those who had a low average methadone dose at the initial stable stage of treatment (≤35 mg/day vs. >65 mg/day; HR = 1.39, 95% CI: 1.19-1.63).

CONCLUSIONS

Shanghai has been facing the challenge of keeping a high MMT retention rate. Increasing the use of methadone tapering after a stable treatment stage with sufficient dosage could be attempted in the MMT program, as well as considering comprehensive interventions among specific populations, such as young, poorly educated, opiate-positive and needle sharing individuals.

A randomized controlled trial to evaluate the relative efficacy of the addition of a psycho-social intervention to standard-of-care services in reducing attrition and improving attendance among first-time users of methadone maintenance treatment in China

Although methadone maintenance treatment (MMT) is an important means of HIV control, MMT clinics commonly have high attrition rates. The randomized controlled trial investigated the relative efficacy of adding a psycho-social intervention to the standard-of-care MMT in reducing attrition and non-attendance among first-time newly admitted MMT users in China (n = 288). Social workers implemented this three-phase intervention that was based on a behavioral maintenance theory. It also involved participants' family members and rectified some MMT-related misconceptions. As compared to the control group, the intervention group showed significantly lower likelihood of attrition (HR = 0.55, 95% confidence interval 0.39-0.80), lower estimated probability of attrition at Month 12 (0.35 vs. 0.55), and higher median number of days of attendance (Month 6: 147 vs. 91 days, p < 0.001; end-date: 225 vs. 142 days, p < 0.001). Further psycho-social services and translational research are warranted.

What are the factors associated with HIV testing among male injecting and non-injecting drug users in Lashio, Myanmar: a cross-sectional study

OBJECTIVES

HIV testing is an effective intervention for reducing HIV risk and providing information on HIV status. However, uptake of HIV testing is a major challenge within the drug-using population due to the stigma and discrimination associated with their illegal drug use behaviours. This study thus aimed to identify factors associated with HIV testing among injecting drug users (IDUs) and non-injecting drug users (NIDUs) in Lashio, Myanmar.

DESIGN

A cross-sectional study was conducted from January 2010 to February 2010.

SETTING

This study was carried out in Lashio city, Northern Shan State, Myanmar.

PARTICIPANTS

In total, 158 male IDUs and 210 male NIDUs were recruited using a respondent-driven sampling method.

PRIMARY OUTCOME MEASURES

Proportion of both drug users who were ever tested for HIV and factors associated with HIV testing.

RESULTS

Approximately 77% of IDUs and 46% of NIDUs were ever tested for HIV. The multivariate analysis revealed that having ever received drug treatment was positively associated with HIV testing among both IDUs (adjusted OR (AOR) 13.07; 95% CI 3.38 to 50.53) and NIDUs (AOR 3.58; 95% CI 1.38 to 9.24). IDUs who were married (AOR 0.24; 95% CI 0.06 to 0.94) and who injected at least twice daily (AOR 0.30; 95% CI 0.09 to 0.97) were less likely to undergo HIV testing. Among NIDUs, those who belonged to Shan (AOR 0.30; 95% CI 0.11 to 0.84) or Kachin (AOR 0.30; 95% CI 0.10 to 0.87) ethnicities were less likely to test for HIV.

CONCLUSIONS

IDUs and NIDUs who have received drug treatment are more likely to test for HIV. Integrating HIV testing into drug treatment programmes alongside general expansion of HIV testing services may be effective in increasing HIV testing uptake among both IDUs and NIDUs in the Northern Shan State of Myanmar.

Gender differences in abusers of amphetamine-type stimulants and ketamine in southwestern China

The objective of this study was to investigate abuse conditions of new-type drugs for users who are seeking treatment, gender differences, and differences between the amphetamine-type stimulants (ATS) users and mixed amphetamine-type stimulants and ketamine (ATS+K) poly-drug users. A retrospective analysis was conducted of patients with a final diagnosis of the substance use disorder according to the Diagnoses and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) who underwent treatment for exposure to new-type drugs at the mental health center of the West China Hospital from March 2009 to May 2011. A questionnaire was used to collect information about socio-demographics, drug abuse conditions and psychiatric co-morbidities. Male subjects were older (p=0.026), had low level education (p=0.003), were less previously married (p<0.001), were more likely to be employed and to hold higher status jobs (p=0.007); 77.1% of subjects had a psychotic disorder, 28.0% of subjects had a mood disorder, 39.7% had an anxiety disorder, and 45.0% had a cognitive impairment disorder. More men used methamphetamine MA (p<0.001), tobacco (p=0.014) and more than one drug substance (p=0.004) compared to women; women were more vulnerable to mood disorders (p=0.034) than men. For the males, the ATS+K patients were more likely to use 3, 4-methylenedioxymethamphetamine MDMA (p<0.001) and develop more psychotic disorders (p=0.04) than the ATS patients; for females, the ATS+K patients were more likely to use MDMA (p=0.002), alcohol (p=0.014) and develop more cognitive impairment disorder (p=0.034). The present study found that the new-type drug patients have a high degree of psychiatric morbidities; more men were using MA, tobacco and multi-substance and more women patients experience mood disorder in the gender differences. For the males, the ATS+K patients were more likely to use MDMA (3, 4-methylenedioxymethamphetamine) and develop more psychotic disorders than the ATS patients; for females, the ATS+K patients were more likely to use MDMA, alcohol and develop more cognitive impairment disorder. These results suggested that the psychiatrists should focus on the mood disorder among females, psychotic disorders among males who abuse ATS and ketamine, and cognitive impairment disorder for the females who abuse ATS and ketamine.

Assessing the effects of drug misuse on HIV/AIDS prevalence

Drug misuse (injecting drug users-IDU) has been recognized to have a significant effect on the spread of HIV/AIDS epidemic. A deterministic model to assess the contribution of drug misuse and sex in the spread of HIV/AIDS is investigated. The threshold parameters of the model are determined and stabilities are analysed. Analysis of the reproduction number has shown that increase in drug misuse results in an increase in HIV infections. Furthermore, numerical simulations of the model show that drug misuse enhances HIV transmission and progression to AIDS. Thus, in a population with intravenous drug users, advocating for safe sex alone will not be enough to control the HIV/AIDS epidemic.

Risk factors associated with HIV/HCV infection among entrants in methadone maintenance treatment clinics in China: a systematic review and meta-analysis

BACKGROUND

Methadone maintenance treatment (MMT) has rapidly expanded in China, from 8 pilot sites to 696 clinics covering 27 provinces, during 2004-2010. This study evaluates the demographic characteristics and drug use behaviors associated with Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV) infections among MMT entrants through a systematic review and meta-analysis of published literature.

METHODS

Thirty-nine eligible articles (1 in English and 38 in Chinese) were selected for this review. We extracted the relevant indicator information from all eligible studies and performed meta-analyses, by stratifying according to sex of the participants, age groups and drug use behaviors. Five provinces (i.e., Yunnan, Guizhou, Sichuan, Guangxi and Xinjiang) with the population size of HIV-infected drug users greater than 10,000 were defined as high transmission areas (HTAs) for HIV infection; whereas the remaining twenty-six Chinese provinces were considered as low transmission areas (LTAs).

RESULTS

The odds of being infected by HIV among male drug users were significantly higher than for females in high transmission areas (OR=1.49, 95% CI: 1.11-1.99, k=9), while the opposite results were observed in low transmission areas (OR=0.46, 0.27-0.79, k=11). In comparison, no significant differences in risk behaviors were found between sexes in HTAs and LTAs. Younger age was not associated with risk of HIV infection, but was associated with higher risk of HCV infection (<30 years OR=1.88; 30-40 years OR=2.21, compared with >40 years, k=17). Risk of HIV infection was higher among injectors than non-injectors (OR=4.29, 2.70-6.79, k=14) and for those who inject, there was greater risk among sharers than non-sharers (OR=2.47, 1.44-4.23, k=4). Similar patterns were also observed in HCV infection (injectors: OR=10.82, 7.60-15.40; sharers: OR=3.41, 2.56-4.54, k=7).

CONCLUSIONS

Characteristics of MMT entrants positive for HIV or HCV in China vary by disease types, geographical region, sex, age, and injecting behavior. These factors need to be considered in targeted interventions for MMT participants, such as age-specific health education and psychological treatment, antiretroviral therapy and needle-syringe exchange programs.

Methadone maintenance treatment in China: perceived challenges from the perspectives of service providers and patients

BACKGROUND

China has recently adopted methadone maintenance treatment (MMT) as a national strategy to address the problem of drug abuse and related public health issues such as HIV and HCV infections. However, low enrollment and retention rates suggest that barriers may exist in MMT utilization. This study examined both patients' perceptions and service providers' perceptions of challenges in MMT implementation in China.

METHODS

Four focus groups were conducted in two Chinese cities, Shanghai and Kunming, to explore the perceived and experienced barriers in MMT participation in China. All focus group discussions with participants were audio taped and transcribed. Atlas.ti 5.1 was used to analyze data.

RESULTS

Service providers and patient participants reported positive experiences (e.g. effects of MMT in curbing withdrawal symptoms) but also expressed concerns about side effects and continued heroin use during MMT. They also identified barriers in participating and remaining in MMT, including affordability (fee requirement), acceptability (methadone as a substitution, dose, long-term nature), accommodation and accessibility (inconvenient operation hours, lack of transferability to other MMT clinics during travel) and competition between public health and public security.

CONCLUSIONS

The present findings have implications for reconsidering the current MMT policies and practices in order to improve access, utilization and, ultimately, the effectiveness of MMT in China.

Describing the Chinese HIV surveillance system and the influences of political structures and social stigma

China’s public health surveillance system for HIV was established in late 1980s and has evolved significantly during the past three decades. With the gradually changing mode of HIV transmission from sharing of intravenous injecting equipment to sexual exposure and the rapid spread of HIV infection among Chinese homosexual men in recent years, an efficient and comprehensive population-level surveillance system for describing epidemics trends and risk behaviours associated with HIV acquisition are essential for effective public health interventions for HIV. The current review describes the overall strength of the Chinese HIV surveillance system and its structural weaknesses from a political and social perspective. The HIV surveillance system in China has undergone substantial revamping leading to a comprehensive, timely and efficient reporting system. However, large data gaps and lack of quality control and sharing of information obstruct the full performance of the system. This is largely due to fragmented authoritarianism brought about by the underlying political structure. Social stigma and discrimination in health institutes are also key barriers for further improvements of HIV diagnosis and surveillance in China.

Misconceptions predict dropout and poor adherence prospectively among newly admitted first-time methadone maintenance treatment clients in Guangzhou, China

AIMS

To investigate the incidence of dropout and the prevalence of poor adherence among newly admitted first-time clients of methadone maintenance treatment (MMT) clinics, and the associations between MMT-related misconceptions and these two treatment outcomes.

DESIGN

A cohort study (maximum follow-up period = 17.6 months) was conducted.

SETTING

Three of the nine MMT clinics in Guangzhou, China participated in the study.

PARTICIPANTS

The sample included 158 newly admitted first-time MMT clients.

MEASUREMENTS

Information collected included background characteristics, history of drug use, MMT-related misconceptions, dropout during the entire study period and poor adherence within the first 6 months since admission to MMT.

FINDINGS

Of all newly admitted MMT clients, 98.2% possessed at least one and 50.6% possessed all four types of MMT-related misconception; 51.3% had dropped out before the completion of the study [95% confidence interval (CI): 43.5-59.1%] and 62% exhibited poor adherence within the first 6 months since admission (95% CI: 54.2-69.6%). Adjusting for significant background variables, the number of misconceived responses predicted significantly both dropout [hazard ratio (HR) = 3.80 for two to three misconceived items, HR = 7.13 for four misconceived items, with zero to one misconceived item being the reference] and poor adherence within the first 6 months [relative risk (RR) = 4.13 for two to three misconceived items; RR = 4.40 for four misconceived items, with zero to one misconceived item being the reference.

CONCLUSIONS

Among opiate addicts in China prescribed methadone maintenance therapy for the first time, misconceptions about this medication are prevalent and are associated with poor adherence to the medication regimen and a high a rate of dropout from the treatment programme.

Net financial benefits of averting HIV infections among people who inject drugs in Urumqi, Xinjiang, Peoples Republic of China (2005-2010)

BACKGROUND

To quantify the contribution of locally implemented prevention programmes in contributing to reductions in treatment and care costs by averting HIV infections among those who inject drugs this study calculates net financial benefit of providing harm reduction programmes using information from services being implemented in Urumqi, Xinjiang Uighur Autonomous Region of China ( between 2005 and 2010).

METHODS

Information was collected to assess cost of providing methadone treatment (MMT) and needle and syringe programmes (NSP). HIV incidence was estimated among people who inject drugs (PWID). HIV infections averted were calculated. Net benefit was assessed by estimating costs of providing prevention programmes and comparing these to the costs of providing care.

RESULTS

An estimated 5678 (range 3982-7599) HIV infections were averted between 2005 and 2010 and the net financial benefit of providing harm reduction programmes compared to treatment and care costs for HIV infections averted was USD 4.383 million during the same time period.

CONCLUSION

These results demonstrate the net and accumulating benefit of investing in harm reduction programmes for PWID in Urumqi. The return on investment progressively increased during the time period studied and it is clear that these cost savings will continue to accrue with the continued implementation of HIV prevention interventions in the community that include harm reduction programmes targeted at PWID.

HIV/AIDS and drug use in China--interactions, impacts, and issues

The interrelationships of HIV/AIDS and drug use and misuse result in complex problems that have been addressed by a variety of sociolegal approaches that often are in contrast to evidence-based medical practices proven effective in reducing associated harms. Like other countries struggling to reduce the incidence and consequences of addiction and HIV/AIDS, China is working to improve systems of care and to revise policies toward drug use and misuse and HIV/AIDS. Greater interaction with researchers and clinicians from around the world can foster increased awareness of effective practices and help implement effective strategies to deal with the problems of HIV/AIDS, and addiction.

Misconceptions toward methadone maintenance treatment (MMT) and associated factors among new MMT users in Guangzhou, China

The methadone maintenance treatment (MMT) program is scaling up in China, but little is known about drug users' cognitions of MMT. To investigate the prevalence and associated factors of MMT-related misconceptions, a totally of 300 newly admitted MMT users were interviewed in three MMT clinics in Guangzhou. Four statements were used to assess MMT-related misconceptions. The results showed that the majority of participants misconceived that MMT is intended primarily for detoxification (92.3%), that one could be completely detoxified and quit using methadone after using it for 2-3months (64.2%), that MMT is not a long-term or even lifetime treatment (77.9%); and that one should attempt to reduce its treatment dosage as methadone is harmful to one's health (84.3%); 48.5% of the respondents possessed all four types of misconceptions. Prior experience of methadone use in voluntary drug detoxification centers (OR=1.82 to 2.55, p<0.05) was associated with some misconception items, whilst being introduced by some peer drug users or community members to use MMT (versus not being introduced by anyone; OR=0.38 to 0.50, p<0.05), having taken up HIV voluntary counseling and testing prior to admission (OR=0.52, p<0.05), and a higher HIV-related knowledge level (OR=0.38, p<0.05) were associated with lower likelihoods for possessing some of the misconceptions. The findings suggested that MMT-related misconceptions were very prevalent among newly recruited MMT users in China. Misconceptions are potential factors causing drop-outs. Interventions targeting such misconceptions are greatly warranted.

Drug use in rural China: a preliminary investigation in Hunan Province

AIMS

To compare characteristics and illicit drug abuse patterns among drug abusers in rural and urban areas of Hunan Province, China. MEASUREMENTS AND DESIGN: Data collected by public security bureau on newly registered drug abusers between 2005 and 2008 in five urban and five rural areas (n = 1639) were extracted anonymously and analyzed.

SETTING AND PARTICIPANTS

All newly registered drug users in urban (n = 812) and rural (n = 827) areas of Hunan Province were included.

FINDINGS

Drug users from the rural areas were younger [31 (6.6) versus 34 (8.0) years, P < 0.001], with a higher proportion of males (86% versus 82%, P < 0.05) or married (34% versus 27%, P < 0.01). Rural drug users reported an earlier onset of drug use [27 (5.9) versus 30 (7.9) years old, P < 0.001], were more likely to report heroin as their primary drug of abuse (53% versus 47%, P < 0.001) and had a lower prevalence of criminal activities (19% versus 31%, P < 0.001). Rural drug users were less likely to report needle sharing (1.8% versus 4.3%, P < 0.01), less likely to report being human immunodeficiency virus positive (0.8% versus 2.6%, P < 0.01) and less likely to report prior drug treatment participation (2.8% versus 6.8%, P < 0.001).

CONCLUSIONS

Drug abuse is a substantial problem in both urban and rural areas in China. The very low proportion of newly registered drug users reporting any prior drug abuse treatment points to the importance of expanding substance abuse treatments, especially in rural areas where treatment penetration is even lower than in urban areas.

Drug policy in Vietnam: a decade of change?

BACKGROUND

Driven by the rapid spread of HIV, Vietnam's response to drug use has undergone significant transformation in the past decade. This paper seeks to identify and analyse factors that prompted these changes and to investigate their impact on the lives of people who use drugs.

METHOD

This policy analysis is based on a review of Vietnamese Government documents, peer-reviewed publications and the authors' knowledge of and involvement in drug policy in Vietnam.

RESULTS

The last decade has witnessed a progressive change in the mindset of political leaders in Vietnam around illicit drug use and HIV issues. This has led to adoption of evidence-based interventions and the evolution of drug policy that support the scale up of these interventions. However, HIV prevalence among drug users at 31.5% remains high due to limited access to effective interventions and impediments caused by the compulsory treatment centre system.

CONCLUSIONS

The twin epidemics of HIV and illicit drug use have commanded high-level political attention in Vietnam. Significant policy changes have allowed the implementation of HIV prevention and drug dependence treatment services. Nevertheless, inconsistencies between policies and a continued commitment to compulsory treatment centres remain as major impediments to the provision of effective services to drug users. It is critical that Vietnamese government agencies recognise the social and health consequences of policy conflicts and acknowledge the relative ineffectiveness of centre-based compulsory treatment. In order to facilitate practical changes, the roles of the three ministries directly charged with HIV and illicit drug use need to be harmonised to ensure common goals. The participation of civil society in the policymaking process should also be encouraged. Finally, stronger links between local evidence, policy and practice would increase the impact on HIV prevention and drug addiction treatment programming.

Effects of a randomized contingency management intervention on opiate abstinence and retention in methadone maintenance treatment in China

AIMS

Methadone maintenance treatment has been made available in China in response to the rapid spread of human immunodeficiency virus (HIV), but high rates of dropout and relapse are problematic. The aim of this study was to apply and test if a contingency management (or motivational incentives) intervention can improve treatment retention and reduce drug use.

DESIGN

Random assignment to usual care with (n = 160) or without (n = 159) incentives during a 12-week trial. Incentives participants earned draws for a chance to win prizes on two separate tracks targeting opiate-negative urine sample or consecutive attendance; the number of draws increased with continuous abstinence or attendance.

SETTING

Community-based methadone maintenance clinics in Shanghai and Kunming.

PARTICIPANTS

The sample was 23.8% female, mean age was 38, mean years of drug use was 9.4 and 57.8% had injected drugs in the past 30 days.

MEASUREMENTS

Treatment retention and negative drug urine.

FINDINGS

Relative to the treatment-as-usual (control) group, better retention was observed among the incentive group in Kunming (75% versus 44%), but no difference was found in Shanghai (90% versus 86%). Submission of negative urine samples was more common among the incentive group than the usual care (74% versus 68% in Shanghai, 27% versus 18% in Kunming), as was the longest duration of sustained abstinence (7.7 weeks versus 6.5 in Shanghai, 2.5 versus 1.6 in Kunming). The average total prize amount was 371 Yuan (or $55) per participant (527 for Shanghai versus 216 in Kunming).

CONCLUSIONS

Contingency management improves treatment retention and drug abstinence in methadone maintenance treatment clinics in China, although there can be considerable site differences in magnitude of effects.

Yulu Shequ - a unique rehabilitation program for illicit drug users in Kaiyuan in southwest China

Introduction

In China, illicit drug use and addiction have been rapidly increasing over the last two decades. Traditional compulsory rehabilitation models in China are widely considered ineffective. Recently, a new model of drug user rehabilitation called the 'Yulu Shequ Program' has gained a national reputation for successful rehabilitation in the city of Kaiyuan in southwest China. The aim of this study was to describe this program to the international public and to assess the program's effectiveness in terms of relapse rates and costs to participants and public payers.

Case description

The Yulu Shequ program provides up to one hundred participants at any point in time with the opportunity to live and work in a purpose-built, drug-free community after completing compulsory rehabilitation. The length of stay is not limited. Community members receive medical and psychological treatment and have the option to participate in social activities and highly valued job skills training. The program has very strict policies to prevent illicit drugs entering the community.

Evaluation

The evaluation was carried out through 1) a review of literature, official documents and websites in Chinese language describing the program and 2) an on-site visit and conduct of semi-structured interviews with key staff members of the Yulu Shequ program. The relapse rate in 2007 was 60% compared to 96% in the compulsory program. Annual costs to public payers of CNY4800 (US$700) were largely offset by income earned through on-site labour by participants totalling CNY4600 (US$670).

Conclusions

The Yulu Shequ program is an interesting model for drug rehabilitation that could lead the way for a new Chinese national policy away from compulsory rehabilitation towards a more collaborative and effective approach. Caution is needed when interpreting relapse rates as Yulu Shequ participants need to have completed compulsory rehabilitation before entering the program. A more comprehensive evaluation of this program would be desirable before implementation in other parts of China or in other countries facing similar problems.