Keming Rou

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

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

Effectiveness of first eight methadone maintenance treatment clinics in China.

Objective:To evaluate the effectiveness of the first phase of eight methadone maintenance treatment (MMT) clinics in China. Design:Repeated cross-sectional surveys. Methods:Three surveys of clients attending the first phase of eight MMT clinics were carried out at entry, and 6 and 12 months after enrolment. Drug using behaviours, drug-related criminal activity, and relationships with families were compared for the three periods. Blood specimen were collected and tested for HIV for each client at entry, and HIV-negative clients were re-tested after 12 months. Results:A total of 585, 609 and 468 clients participated in the first, second and third surveys, respectively. The proportion of clients who injected drugs reduced from 69.1 to 8.9 and 8.8%, and the frequency of injection in the past month had reduced from 90 times per month to twice per month, employment increased from 22.9 to 43.2 and 40.6%, and self-reported criminal behaviours reduced from 20.7 to 3.6 and 3.8% in the three surveys. By the third survey, 65.8% of clients reported a harmonious relationship with families, an increase from 46.8% at entry, and 95.9% of clients were satisfied with MMT services. Eight HIV seroconversions were found among 1153 clients during 12 months. Conclusion:The study demonstrated that the first phase MMT contributed to a reduction in drug use, drug injecting behaviours, drug-related criminal behaviours, HIV infections, and improved relationships within families among heroin users who participated in the MMT programme. MMT needs to be scaled up nationwide rapidly with improved services.

Evaluation of a needle social marketing strategy to control HIV among injecting drug users in China.

Objective:To evaluate the effectiveness of a needle social marketing strategy to reduce needle sharing and hepatitis C Virus (HCV)/HIV transmission among injecting drug users (IDU) in China. Design:Two-armed, prospective, community-randomized prevention trial. Setting:Four counties/townships in Guangxi and Guangdong provinces; one randomized to intervention the other to control in each province. Participants:Injecting drug users: 823 (443 intervention, 382 control) at baseline and 852 (415 intervention, 407 control) at the second cross-sectional survey 12 months later. Intervention:A needle social marketing programme, including promotion of safe injection norms and increased access to clean needles over a 12 month period. Main outcome measures:Cross sectional surveys at baseline and follow-up compared changes in drug using behaviours and HIV and HCV rates in the intervention and control communities. Results:Needle sharing behaviours were similar in the two groups at baseline (68.4 vs. 67.8%), and dropped significantly to 35.3% in the intervention community and remained relatively stable in the control community (62.3%; P < 0.001). In a subset of cohort of new injectors, the incidence of HCV was significant lower in intervention than in control in both provinces (P < 0.001, P = 0.014) and overall (P < 0.001) but HIV was only significantly lower in intervention in Guangdong (P = 0.011). Conclusion:Needle social marketing can reduce risky injecting behaviour and HIV/HCV transmission among injecting drug users in China and should be expanded.

Scaling up prevention programmes to reduce the sexual transmission of HIV in China.

Background Since 2007, sex has been the major mode of HIV transmission in China, accounting for 75% of new infections in 2009. Reducing sexual transmission is a major challenge for China in controling the HIV epidemic. Methods This article discusses the pilot programmes that have guided the expansion of sex education and behavioural interventions to reduce the sexual transmission of HIV in China. Results Commercial sex became prevalent across China in the early 1980s, prompting some health officials to become concerned that this would fuel an HIV epidemic. Initial pilot intervention projects to increase condom use among sex workers were launched in 1996 on a small scale and, having demonstrated their effectiveness, were expanded nationwide during the 2000s. Since then, supportive policies to expand sex education to other groups and throughout the country have been introduced and the range of targets for education programmes and behavioural interventions has broadened considerably to also include school children, college students, married couples, migrant workers and men who have sex with men. Conclusions Prevention programmes for reducing sexual transmission of HIV have reasonable coverage, but can still improve. The quality of intervention needs to be improved in order to have a meaningful impact on changing behaviour to reducing HIV sexual transmission. Systematic evaluation of the policies, guidelines and intervention programmes needs to be conducted to understand their impact and to maintain adherence.

Quality of life of children living in HIV/AIDS-affected families in rural areas in Yunnan, China.

Abstract The aim of this study was to explore the main influencing factors of the health-related quality of life (HRQL) of children living in HIV/AIDS-affected families in rural areas in Yunnan, China. The HRQL of 116 children aged 8–17 from HIV/AIDS-affected families and 109 children from unaffected families was evaluated by the Chinese Version of PedsQLTM 4.0. Some potential influencing factors were questioned, such as demographic characteristics, the families’ social and economic status, foster models, childrens self-esteem, etc. The HRQL of childrens caregivers may also have been among the influencing factors, as measured by short-form 36 (SF-36). Multiple regression analysis was used to explore the influence of independent variables on childrens HRQL. The findings showed that children from HIV/AIDS-affected families reported lower scores of HRQL than those from unaffected families, especially in domains of psychosocial functioning, emotional functioning, and school functioning. Results of multiple regression analysis showed that lower levels of childrens self-esteem and caregivers’ SF-36 reduced the majority of PedsQL domains. Children living with grandparents reported higher PedsQL scores in psychosocial health, social functioning, and school functioning. Disclosure of parental HIV/AIDS status reduced childrens PedsQL scores in emotional functioning and social functioning. Caregivers spending more hours accompanying the children appeared to increase the PedsQL scores in psychosocial health and school functioning. The findings indicate that the childs self-esteem, the caregivers perceived quality of life, the childs foster pattern, the average hours of company provided by the caregiver, and whether the child was informed of the parents HIV/AIDS status are important factors influencing HRQL. Interventions aiming at these factors should be developed to improve the HRQL of children affected by HIV/AIDS.

Structural-level factors affecting implementation of the methadone maintenance therapy program in China

This study identifies structural-level factors influencing methadone maintenance therapy (MMT) program implementation in China. Twenty-eight service providers and 560 randomly selected clients from 28 MMT clinics in the study area underwent face-to-face interviews. Number of clients, retention rate, coverage, and structural-level factors were collected from a survey of service providers. Individual-level factors and self-reported illicit drug use information were obtained from clients. Urine specimens were collected from the client participants to test for heroin use. Clinics affiliated with the local Centers for Disease Control and Prevention (CDC) had more clients, higher retention rates, and broader coverage than those not affiliated with the CDC. Longer operating hours, incentive for compliant clients, and comprehensive services were positively associated with client recruitment and coverage. Comprehensive services and incentives for compliant clients were negatively associated with concurrent illicit drug use. Comprehensive services should be incorporated into the MMT program. Extended operating hours and incentives for compliant clients should be implemented.

The first community-based sexually transmitted disease/HIV intervention trial for female sex workers in China.

Objectives:This study was the first community-based intervention to test feasibility and effectiveness of an intervention targeting sex workers in China. Design:Prospective, community-based, pre/post-intervention trial. Method:Thirty establishments in Chengjiang, 34 in Ruili and 23 in Longchuan were selected for the study. The study participants were female sex workers. Out-reach workers visited the establishments to conduct intervention activities over 6 weeks. The activities included lectures, discussion, video and audio cassettes, and distribution of educational folders and condoms. Pre- and post-intervention cross-sectional surveys assessed changes in sexually transmitted disease (STD)/AIDS knowledge and condom use. Results:After the intervention, knowledge of the three HIV transmission routes increased from 25 to 88% (P < 0.01), knowledge that condoms can reduce the risk of STD/HIV infection increased from 56 to 94% (P < 0.01). Condom use at last sex and in the last three sexual encounters increased from 61 to 85% (P < 0.01) and from 41 to 70%, respectively. Multivariate analyses indicated that the intervention was an independent factor (P < 0.01) for these changes. Conclusion:The intervention programme was effective at increasing HIV/AIDS knowledge and condom use rates among sex workers in the community and should be expanded.

Challenges in providing services in methadone maintenance therapy clinics in China: Service providers' perceptions

BACKGROUND The Methadone Maintenance Therapy (MMT) program has been initiated in China since 2004. As of the end of November, 2008, 558 MMT clinics had been established countrywide. The objective of this study was to elucidate the difficulties and challenges as perceived by service providers working in MMT clinics. METHODS One service provider from each of the 28 MMT study clinics in Zhejiang and Jiangxi Provinces of China participated in a face-to-face in-depth interview for about 1-2h to describe their perceptions of working in MMT clinics. Qualitative data were analysed using ATLAS.ti. The grounded theory was used to guide the data analysis. RESULTS Participants identified major problems in providing services in MMT clinics including lack of resources, professional training, and institutional support. Difficulties in pursuit of career, concern for personal safety, low income, heavy working load, and poor opinion of MMT by Chinese society often contributed to greater stress and burnout among the service providers. CONCLUSION The MMT programs in China desperately need additional resource allocation and institutional support for the current and perhaps future expansion of the programs. The service providers are in urgent need of professional training to improve the quality of care they can offer MMT clients.

Antiretroviral Therapy Reduces HIV Transmission in Discordant Couples in Rural Yunnan, China

Background Although HIV treatment as prevention (TasP) via early antiretroviral therapy (ART) has proven to reduce transmissions among HIV-serodiscordant couples, its full implementation in developing countries remains a challenge. In this study, we determine whether Chinas current HIV treatment program prevents new HIV infections among discordant couples in rural China. Methods A prospective, longitudinal cohort study was conducted from June 2009 to March 2011, in rural Yunnan. A total of 1,618 HIV-discordant couples were eligible, 1,101 were enrolled, and 813 were followed for an average of 1.4 person-years (PY). Routine ART was prescribed to HIV-positive spouses according to eligibility (CD4<350 cells/µl). Seroconversion was used to determine HIV incidence. Results A total of 17 seroconversions were documented within 1,127 PY of follow-up, for an overall incidence of 1.5 per 100 PY. Epidemiological and genetic evidence confirmed that all 17 seroconverters were infected via marital secondary sexual transmission. Having an ART-experienced HIV-positive partner was associated with a lower rate of seroconvertion compared with having an ART-naïve HIV-positive partner (0.8 per 100 PY vs. 2.4 per 100 PY, HR = 0.34, 95%CI = 0.12–0.97, p = 0.0436). While we found that ART successfully suppressed plasma viral load to <400 copies/ml in the majority of cases (85.0% vs. 19.5%, p<0.0001 at baseline), we did document five seroconversions among ART-experienced subgroup. Conclusions ART is associated with a 66% reduction in HIV incidence among discordant couples in our sample, demonstrating the effectiveness of Chinas HIV treatment program at preventing new infections, and providing support for earlier ART initiation and TasP implementation in this region.

Factors Associated With Mortality of HIV-Positive Clients Receiving Methadone Maintenance Treatment in China

BACKGROUND Little is known about mortality of opiate users attending methadone maintenance treatment (MMT) clinics. We sought to investigate mortality and its predictors among human immunodeficiency virus (HIV)-positive MMT clients. METHODS Records of 306 786 clients enrolled in Chinas MMT program from 24 March 2004 to 30 April 2011 were abstracted. Mortality rates were calculated for all HIV-positive antiretroviral treatment (ART)-naive and ART-experienced clients. Risk factors were examined using stratified proportional hazard ratios (HRs). RESULTS The observed mortality rate for all clients was 11.8/1000 person-years (PY, 95% confidence interval [CI], 11.5-12.1) and 57.2/1000 PY (CI, 54.9-59.4) for HIV-positive clients (n = 18 193). An increase in average methadone doses to >75 mg/day was associated with a 24% reduction in mortality (HR = 0.76, CI, .70-.82), a 48% reduction for ART-naive HIV-positive clients (HR = 0.52, CI, .42-.65), and a 47% reduction for ART-experienced HIV-positive clients (HR = 0.53, CI, .46-.62). Among ART-experienced clients, initiation of ART when the CD4(+) T-cell count was >300 cells/mm(3) (HR = 0.64, CI, .43-.94) was also associated with decreased risk of death. CONCLUSIONS We found high mortality rates among HIV-positive MMT clients, yet decreased risk of death, with earlier ART initiation and higher methadone doses. A higher daily methadone dose was associated with reduced mortality in both HIV-infected and HIV-uninfected clients, independent of ART.