Current status of drug use and HIV/AIDS prevention in drug users in China

Abstract

The objective of this paper is to review the current status of drug use and HIV/AIDS prevention for drug users in China and provide scientific evidence for HIV/AIDS prevention and control in drug users. Literature and articles related to drug abuse in China, as well as the results of prevention efforts and successful cases regarding HIV/AIDS prevention in drug users, are reviewed. Lessons learned are drawn out for the future improvement of work and the sustainable development of treatment programs. The number of drug users in China is increasing. Even though the number of opioid-type drug users is growing more slowly than in the past, the number of amphetamine-type stimulant users has increased sharply. It has been proven that methadone maintenance treatment and syringe exchange programs gradually and successfully control HIV/AIDS transmission in drug users. However, it is necessary to enhance these prevention methods and expand their coverage. In addition, the strengthening of antiretroviral therapy (ART) treatment for HIV-infected drug users is crucial for HIV/AIDS prevention and control. The rapidly growing number of amphetamine-type stimulant users, along with their high-risk behavior, poses a hidden danger of greater HIV/AIDS transmission through sexual intercourse in the near future.

1. Background

Since the reporting of the prevalence of AIDS in injecting drug users began in China in 1989, the injection of drugs has become one of the primary channels of HIV infection in China. Currently, China has approximately 2 million drug users, and government departments, along with some organizations, are taking various measures to prevent and control the transmission of AIDS within this group. While there have been positive results from these measures, a series of challenges have also arisen. In order to provide scientific evidence and recommendations for future work in the prevention of HIV/AIDS in drug users, this article reviews the current status of drug use in China as well as the HIV/AIDS prevention work being done within the drug-user community.

2. Method

Through the review of the current status of drug use in China, as well referral to the literature related to HIV/AIDS prevention work and the summarizing of successful experiences, we will make recommendations for facilitating future HIV/AIDS prevention work and its sustainable development.

3. Result

3.1 Current status of drug use in China

From the late 1970s to the early 1980s, with the development of the “Reform and Opening” economic policy of China, international drug-trade groups transported large amounts of drugs by roads, crossing the border area of Yunnan and Myanmar to Hong Kong, Europe, and America, and made exorbitant profits. Meanwhile, some drugs were sold along the drug trafficking routes and further flowed into broader regions, developing the internal drug consumption market in China. The Chinese government declared in 1988 that drug users were found in the border area of the southwestern part of China. The number of those who were drug-dependent increased to 250,000 in 1992. The drug-demand market gradually expanded from the border area to inland and coastal cities, and then from urban areas to rural areas. China evolved from a transit country for illegal drugs to a big drug consumption market in 10 years. The Narcotic Control Report of China in 2003 showed that the amount of opium and heroin captured, as well as the number of drug users, kept growing and that drug users were found in 2,148 counties all over the country [1].

In addition, with the quickly developing process of urbanization and modernization, the number of drug users continues to increase and the types of drugs being used are becoming more diverse. Beside opium and heroin, other stimulant drugs such as “ice,” MDMA, and ketamine have appeared in the market, and their use has increased sharply. The present status of drug use in China is as follows: the overseas growing and dealing of illegal drugs is still serious and it is an arduous task for narcotics control; the number of opioid-type drug users is still growing and there is an increasing trend in the use of amphetamine-type stimulants; the number of male opioid users is larger than that of female users; most individuals who are opioid-dependent are injecting the drug and more and more people are using multiple drugs; and the relative proportion of opioid-dependent individuals is decreasing, but their absolute number is still growing. By the end of 2011, the number of registered drug users was 1.794 million, with 1.156 million dependent on heroin (accounting for 64.5%). There were 587,000 users of chemical synthetic drugs, accounting for 32.7% of the total number of drug users, an increase of 35.9%. The number of new users of chemical synthetic drugs was 146,000, an increase of 22%. Among these chemical synthetic drug users, those who are under 35 years old account for 67.8%, showing a distinct trend toward younger use. In addition, it has been found that chemical synthetic drugs have further flowed into middle sized cities, towns, and rural areas [1].

3.2 HIV/AIDS in drug users

The Chinese government declared in 1988 that a drug use problem was found in the border area of the southwestern part of China. The number of people who were dependent on drugs increased to 250,000 in 1992. There were 1.794 million registered drug users in 2011, among which 1.065 million were using heroin [2]. Some research has showed that 72.5% of individuals dependent on heroin in China were injecting, and their syringe sharing rate was up to 69.5% [3]. By the end of 2011, it was estimated that there were 780,000 people living with HIV/AIDS in China, and that 28.4% of HIV infection cases are due to injecting drugs [4]. Of the estimated 14.0 million (range: 11.2 million to 22.0 million) people who inject drugs worldwide, UNODC estimates that 1.6 million (range: 1.2 million to 3.9 million) are living with HIV. Overall, the Russian Federation, the United States, and China account for one half (46%) of the global number of people who inject drugs that are living with HIV (21%, 15%, and 10%, respectively) [5].

3.3 HIV/AIDS prevention and control in drug users in China

3.3.1 Methadone maintenance treatment (MMT)

China’s methadone maintenance treatment (MMT) program began in March 2004, with the launching of eight pilot clinics in five provinces. By June 2006, 100 MMT clinics had been established, covering 21 provinces (including autonomous regions and municipalities) and treating 15,678 patients in total. Altogether, every day approximately 8,397 patients are treated, with each clinic treating an average of 84 people each day. By the end of 2012, 756 community-based MMT clinics offered treatment in 28 provinces (including autonomous regions and municipalities); 30 treatment vehicles also offer care. In total, 384,479 people have been treated, with 208,388 currently being treated. Clinics that are currently offering treatment report that, in total, 353,513 people have been tested for HIV, with 7.7% testing positive. In the first screening for the HCV antibody, 58.6% tested positive. In addition, out of 298,298 people screened for syphilis, 4.0% tested positive.

Data show that during the 9 years of the development of China’s MMT program, the pilot phase of the program has been completed, its scope has been widened, and it has become conventional AIDS prevention work. Patients’ daily average drug dosage has risen from 50.5mg in 2008 to 60mg by December 2012, and new HIV infection rates in clients treated in MMT clinics fell from 0.41% in 2008 to 0.30% in 2011. Research in Yunnan Province shows that by the end of 2012, the MMT program had treated a total of 35,993 people, with 14,951 people currently being treated. In order to expand MMT coverage and increase its accessibility, an additional 73 medication-dispensing points have been opened and 3,058 clients have been served. The average number of people being treated in these medication points is 42, accounting for 20.5% of the total number of patients in Yunnan. Data from 2008 to 2012 show that the rate of new HIV infections for those treated in MMT clinics fell from 2.46% to 0.46%. Research by Duan Song et al. (2009, 2011) from Yunnan’s Dehong Prefecture shows that the scale of drug injection in the previous month had fallen from 24.6% to 2.3%, the needle-sharing rate had fallen from 98.2% to 10.9%, and that drug users’ social and familial functions have been gradually restored. It also shows that crime related to drug use has dropped from 42% to 23.6%, with the scale of drug-use related public security cases falling from 62.7% to 32.1% from 2005 to 2009. While in 2008, the new HIV infection rate in Dehong’s drug users stood at 4.3 (per 100 person years), the morbidity of clients treated in Dehong’s MMT clinic in 2008, 2009, and 2010 stood at 0.60, 0.18, and 0.28 (per 100 person years), respectively, thus showing a downward trend [6–9].

3.3.2 Needle exchange program

In 1998, China began its first clean-needle exchange pilot program. After the start of the “China-UK HIV/AIDS Prevention and Care Project” and the “Asia Regional HIV/AIDS Project,” Yunnan, Sichuan, and Xinjiang developed large-scale clean needle exchanges. A harm-reduction program for injecting drug users (IDUs) implemented in Yining City and in three districts in Urumqi City provided services to 4,041 IDUs (40% of estimated drug users in these areas). Of these, 3.2% were unregistered drug users and 11.3% were women. Sharing of needles and syringes dropped by 51.7%, and condom use increased by 44.9% with spouses and 56% with sex workers. Referral services were also provided. Of people using methadone maintenance programs, 20% were referred from the NEP. In total, 177 people were referred for antiretroviral therapy (ART; 45% of the total number of people on ART in these areas) [10].

By July 2007, the four project counties of the Asia Regional HIV/AIDS Project (ARHP) implemented in Yunnan Province supplied service 21,850 times, covering 2,135 injecting drug users (IDUs). The services provided included: distributing 500,663 clean needles/syringes, collecting 323,368 used needles (collection rate of 65%); distributing 11,980 condoms, and supplying abscess treatment service. The project also built a connection with other services, referring patients to the MMT program, HIV Voluntary Counseling Testing (VCT) service, ART, and TB and HIV/AIDS care services (total referrals numbered 1,879 person/times). Through these services, the behavior of the IDUs in the four counties in Yunnan province changed, as shown by the increase in new needle/syringe use with each injection (from 40% in the baseline research to 61% in the follow-up research). We also have seen obvious improvement in condom use in the last incidence of sex, which changed from 1% at baseline to 35% at follow-up. In the follow-up research, over three quarters (79%) of the drug users acquired needles/syringes from outreach workers. The implementation of ARHP did not lead to more people beginning to use drugs, which was a concern of some people before the program began; instead, it promoted positive behavior changes among drug users and reduced the harm related to injecting drug use. The feasibility of this strategy has been shown through real-world practice [11].

In 2007, China set up 775 needle and syringe exchange sites in 405 counties, which covered 45,000 IDUs. These projects actively reduced the HIV infection high-risk behaviors among IDUs [3]. By the end of 2011, an average of 1,052 needle exchange sites across the country conducted clean needle exchange work, with a monthly average of 52,600 IDUs participating. Widespread coverage of needle exchange programs, together with MMT contributes to the prevention of HIV/AIDS among drug users.

3.3.3 Naloxone First Aid Project

Research shows that the mortality rate of injecting heroin users is 48 times higher than people in the general population of the same age, with heroin overdoses accounting for 68% of the deaths. In Yunnan’s Gejiu city alone, of the 3,000 deaths of heroin users, approximately 60% died from heroin overdoses [12]. For a variety of reasons, in the event of drug overdose, the heroin user cannot be saved in time and so death can occur. With harm reduction measures as one part of an intervention plan, Yunnan started a pilot project of the Naloxone Aid Project in Gejiu in 2008, later gradually expanding to pilot projects in Kunming, Mengzi, Kaiyuan, and Yuxi. At the same time, such pilot projects were developed in Zhejiang’s Ningbo, Guangxi, and Beijing [12,13]. Since the start of the Naloxone First Aid Project pilot project in Yunnan, 769 people have successfully been saved from potential overdoses.

4. Challenges

By the end of 2011, public security bodies across the country took in 92,000 drug users for drug detoxification, and there were 227,000 people in compulsory detoxification centers [1]. By the end of 2011, China’s 28 provinces (including autonomous regions and municipalities) had a total of 738 MMT clinics, with a total of 344,254 people treated and 140,102 being treated. There is an average of 1,052 needle exchange dispensing points carrying out work, with a monthly average of 52,600 people taking part in the program.

In 2011 the number of drug users who received AIDS prevention and control services stood at 496,000, including the 227,000 drug users in compulsory detoxification centers, the 36,000 in community-based detoxification, the 40,000 in community-based rehabilitation, the 140,000 receiving MMT services, as well as the 53,000 in needle exchange programs. This number accounts for 42.91% of the 1,156,000 opioid-type drug users in the country, leaving a considerable number of drug users still not receiving AIDS prevention and control services.

Scientific research from across the world in the past 30 years shows that drug addiction (involving heroin, cocaine, amphetamine, cannabis, nicotine, and alcohol) is a chronic, relapsing brain disease. Due to psychoactive substance use over an extended period, the basic structure and function of the brains of drug addicts are seriously damaged, leading to their “deviant” behavior, which they are not able to control. For a long time, heroin users have been viewed by society as “morally ruined,” “criminal” and “incurable” people, and they are often subject to discrimination, humiliation, marginalization, and criminalization, with some even being cast out by their families. Although the Naloxone First Aid Project pilot program produced good results, there are still some barriers to the widespread running of the program.

Several domestic studies indicate that drug users often have multiple sexual partners and/or concurrent sexual partners, that their use of condoms is relatively low [14,15], and that more drug users are mixing drugs, especially involving amphetamine-style drugs that stimulate the central nervous system [16,17], leading to the danger of transmission of HIV and other sexually transmitted diseases in drug users.

The China AIDS Epidemic Assessment report (2011) shows that by September 2011, a total of 133,524 adults with AIDS received antiretroviral therapy, with 106,593 cases currently receiving treatment. Antiretroviral therapy coverage increased from 62.0% in 2009 to 73.5% in September 2011. However, the high-risk groups’ antiretroviral therapy coverage differs, with studies showing that the coverage of drug users with HIV infection is the lowest at 42.7%. In China, treatment coverage was only one of the risk factors strongly correlated to mortality [18].

5. Suggestions

Improving knowledge in the community that drug addiction is a type of chronic relapsing brain disease, improving public education, strengthening residents’ awareness of equal rights and justice, and reducing the discrimination and stigma that is attached to drug users by the community can lead to the foundation of expanding the coverage of harm reduction work.

Also we should actively encourage drug users’ communities to participate in harm reduction work, strengthen harm-reduction workers’ social-psychological training, change law enforcement officers’ misconceptions about drug users, and improve the coverage and quality of methadone maintenance treatment and needle exchange programs. In order to change the attitudes of policy makers and accelerate the expansion of Naloxone First Aid work, evidence gained through scientific research is suggested to be used for policy advocacy.

It is suggested that HIV counseling and testing for drug users be expanded and that the process of telling people their test results be improved. By strengthening the psychological care and social assistance for people living with HIV/AIDS and encouraging them to join treatment projects as early as possible to realize “Early Detection, Early Care and Early Treatment,” we can realize the “Reduce AIDS Mortality and Reduce HIV new Infections” goal that was set by the 12th 5-year development plan.

Table 1.

Data of registered drug users in China

Year	Registered drug users	ATS users
1990	70000
1991	148000
1992	250000
1994	380000
1995	520000
1997	540000
1998	596000
1999	681000
2000	860000
2001	901000
2002	1000000
2003	1050000
2004	1140000
2005	1160000
2008	1132000	216526
2009	1335900	314072
2010	1545000	432000
2011	1794000	587000

Data resource: Narcotics Control Report of China, Office of Narcotics Control Committee of China