(August 2004) Addressing the problem of injecting drug use represents one of the most difficult public health tasks facing Chinese officials in limiting the spread of HIV/AIDS. At the same time, China must engage drug users and other marginalized groups in testing, counseling, and treatment programs to prevent a generalized epidemic.
Multiple HIV Risks Associated With Injecting Drug Use
The use of contaminated needles in injecting drugs provides the most common HIV transmission route in China. Needle sharing accounted for half of the 62,000 reported HIV cases in 2002.1 Reported cases, however, represent a small proportion of the estimated 1 million people with HIV in China.2 While all 31 provinces of the country have reported infections among drug users,3 the problem is most prevalent among drug users in the seven provinces of Yunnan, Xinjiang, Guangxi, Sichuan, Guizhou, Hunan, and Jiangxi.
Injecting drug use accelerated after China began reforming its economic system in 1979, an effort that opened the country’s doors to foreign trade, travel, and investments. Heroin and opium entered the country from the “golden triangle”—the poppy-growing border area of Myanmar, Laos, and Thailand. Heroin use steadily spread from the border area along trafficking routes to Xinjiang in western China and to prosperous eastern provinces. Today, more than 1 million injecting drug users are registered with China’s Public Security Bureau, although some estimates place the actual total at around 3 million.4
Many drug users heighten their risk of HIV and other infections by engaging in risky behavior, such as needle sharing. To support their habit, some resort to commercial sex work, which provides a conduit for HIV to enter the non-drug-using population. At one surveillance site in Xinjiang, 84 percent of injecting drug users had HIV. In the border town of Ruili in Yunnan—the province that reported the first HIV case among drug users in 1989—around 80 percent of drug users were infected. Infection rates at other surveillance sites in the most affected provinces range from 12 percent to 75 percent.5
The illicit nature of drug use makes this socially marginalized group hard to identify and reach with educational messages and other services. Activities aimed at educating injecting drug users about HIV transmission currently take place at detoxification centers run by the Public Security Bureau at several pilot sites or by international NGOs. The government hopes to expand outreach to 60 percent of drug users within five years through 210 additional outreach centers.6
Authorities also hope to employ a number of “harm-reduction” strategies, including efforts to change risk-taking attitudes and behaviors. Strategies may include: providing injecting drug users with information about HIV transmission; distributing condoms; and offering methadone, a treatment substitute for addicts of heroin and other narcotics.
Methadone Replacement Therapy
Nine methadone clinics currently operate in seven southern and western provinces, serving roughly 1,800 drug users. Methadone is generally provided at no cost to the user either by the government or by a nongovernmental organization (NGO) operating the facility. In five years, the government hopes to have 190 clinics jointly operated by the Public Security Bureau, the health bureau, the Food and Drug Administration, and NGOs. These clinics are expected to provide treatment to more than 50,000 drug users.7
Legalizing Needle Exchanges
The policy environment for harm reduction in China has been liberalized, allowing local authorities to embark on needle-exchange programs. Yunnan province has already legalized the approach with a March 2004 law. Similar programs will increasingly be implemented in the six other provinces where HIV infection among drug users is most prevalent.
These needle-exchange programs will involve educating drug users about HIV transmission and about the importance of using clean injection equipment and of not sharing needles. Users will be encouraged to purchase new equipment at pharmacies or obtain free needles or vouchers for needles at exchange centers set up by the provinces.
The Yunnan law also calls for a number of other important measures. First, it promotes the availability of condoms in hotels, dormitories, and at entertainment establishments. The Public Health Bureau now has the authority to fine hotel and entertainment establishments for not making condoms available.8
In addition, the legislation requires that individuals and entities such as clinics and companies maintain the confidentiality of a person’s HIV status.9 Other provisions relate to the officials’ responsibilities to carry out and enforce the directives. The legislation stipulates punishments—including fines—for government and health officials and doctors who ignore the AIDS law, fail to perform HIV/AIDS surveillance, refuse to treat patients with HIV and AIDS, disclose patients’ personal details, or distribute antiretroviral medicine without approval.10
Overcoming Policy Obstacles
Effective implementation of harm-reduction programs requires the active participation of relevant local communities, including mayors, the court system, and public security officials. Implementing these programs is not simple, however. Some officials oppose public health approaches that seem to condone or support illegal activity. To these officials, needle-exchange programs and condom distribution may appear to be at odds with the bid to legally crack down on drug dealers and drug users.
Addressing the HIV/AIDS high-level meeting of the UN General Assembly in 2003, Executive Vice Minister of Health Gao Qiang highlighted the fine balance that the government hoped to achieve enforcing the country’s laws and promoting HIV prevention and treatment.
“We will improve the laws and regulations and intensify the intervention on dangerous behaviors,” he said. “Public awareness campaigns will be launched, educating the public and encouraging them to participate in the HIV/AIDS prevention and treatment efforts. Illegal acts like drug trafficking, drug use, prostitution, and illegal blood collecting and supplying will be cracked down while a drug-free community and healthy sexual life will be promoted.”11
In the meantime, law enforcement has an opportunity to play a role in harm-reduction strategies, particularly as public security organizations have regular access to injecting drug users through their network of detention centers. Currently, drug users detained by the Public Security Bureau may be sent to detoxification centers for up to six months or to labor camps for reeducation for up to two years.12 These camps, which receive little or no funding from the central or provincial governments, generate revenue through fines levied on new detainees and through daily fees for room and board. The centers earn additional income by putting inmates to work to produce goods that are sold in markets.
The camps’ reliance on inmates to generate operating revenues poses challenges for HIV/AIDS education and methadone programs. Camp operators have little incentive either to suspend work for HIV education and training or to purchase methadone for inmates. However, increased government commitment, including funding for these camps and education and methadone programs within the centers, can improve the management of the detention system and its effectiveness in treating those with HIV and AIDS.
New Resources in the Offing
Chinese programs for injecting drug users will also get a boost in external funding. China has won approval for US$24 million from the Global Fund to Fight AIDS, Tuberculosis and Malaria over two years, as part of a five-year, $63 million proposal to address HIV/AIDS among injecting drug users and sex workers in seven provinces. The money is meant to reduce the spread of HIV/AIDS through a number of activities and free services, including prevention education, voluntary HIV testing, condoms, antiretroviral drugs, treatment for opportunistic infections, methadone maintenance therapy, and needle exchanges. A key goal in the first two years of the project is to test 400,000 people for HIV and to initiate antiretroviral treatment for 15,000 to 25,000 people. Another goal is to offer treatment to 45,000 to 50,000 people by the project’s fifth year.
Some 5 percent of the funding is to go to people living with HIV/AIDS and to groups that they organize. Another 15 percent is to go to NGOs and community-based organizations that are not affiliated with the government.13
Encouraging Signs, but Challenges Ahead
China’s success in preventing a generalized HIV/AIDS epidemic hinges on its ability to test, counsel, and treat injecting drug users and members of other marginalized groups. To this end, there have been several encouraging developments. The country’s leadership has mobilized its bureaucracy, sought new resources, and encouraged new laws and policies that aim to improve the environment for HIV/AIDS prevention and treatment.
However, significant challenges remain. While new national policy directives and local laws do aim to hold government officials responsible for implementing HIV/AIDS programs, the level of support likely to come from public security officials remains uncertain. Addressing the tensions that exist between the need to crack down on illegal activities such as drug use and the bid to carry out harm-reduction strategies could be critical to the success of HIV/AIDS programs.
Drew Thompson is a research associate with the Freeman Chair in China Studies at the Center for Strategic and International Studies (CSIS) in Washington, DC. Mr. Thompson has traveled extensively throughout China and speaks, reads, and writes Mandarin.
- China’s Ministry of Health and the United Nations Theme Group on HIV/AIDS in China, “Joint Assessment Report on HIV/AIDS Prevention and Control in China: June 17, 2003,” accessed online at www.youandaids.org/unfiles/joint_assessment_exec_summary_china.doc, on Aug. 3, 2004.
- Joint United Nations Programme on HIV/AIDS (UNAIDS), 2004 Report on the Global AIDS Epidemic (Geneva: UNAIDS, 2004).
- China’s Ministry of Health and the United Nations Theme Group on HIV/AIDS in China, “Joint Assessment Report on HIV/AIDS Prevention and Control in China: December 1, 2003,” accessed online at www.unaids.org/en/in+focus/topic+areas/prevention.asp, on Aug. 3, 2004.
- China’s Country Coordinating Mechanism, “Reducing HIV transmission among and from vulnerable groups and alleviating its impact in seven provinces in China,” Round 4 HIVAIDS Proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria, accessed online at www.theglobalfund.org/search/portfolio.aspx?countryID=CHN#HIV/AIDS, on Aug. 3, 2004. See also Kaveh Koshnood and Stephanie Weber, “Social Vulnerability of Injection Drug Users to HIV/AIDS in China: Determinants and Responses,” The Yale-China Health Journal 2 (Autumn 2003): 39.
- UN Theme Group on HIV/AIDS in China, “HIV/AIDS: China’s Titanic Peril—2001 Update of the AIDS Situation and Needs Assessment Report” (Geneva: UNAIDS, 2002): 16.
- China’s Country Coordinating Mechanism, Round 4 HIV/AIDS Proposal.
- China’s Country Coordinating Mechanism, Round 4 HIV/AIDS Proposal.
- Order of the People’s Government of Yunnan Province No. 121, Yunnan Sheng Aizibing Fangzhi Banfa (“Responsive Measures for HIV/AIDS Prevention in Yunnan Province”), articles 12, 13, and 24, accessed online at www.yn.xinhuanet.com/ylfzh/fagui/2004/
021001.htm, on Aug. 3, 2004.
- Order of the People’s Government of Yunnan Province No. 121, article 21.
- Order of the People’s Government of Yunnan Province No. 121, articles 22 and 23.
- Gao Qiang, executive vice minister of health, speech at the HIV/AIDS High-Level Meeting of the UN General Assembly, Sept. 22, 2003, accessed online at http://un.fmprc.gov.cn/eng/56493.html, on Aug. 3, 2004.
- Information Office of the State Council of the People’s Republic of China, “Narcotics Control in China” (Beijing: June 2000), accessed online at www.china.org.cn/e-white/1/index.htm, on Aug. 3, 2004. At present, China has a total of 746 compulsory rehabilitation centers and 168 treatment and reeducation-through-labor centers.
- China’s Country Coordinating Mechanism, Round 4 HIV/AIDS Proposal: 87.
For More Information
Here are several other articles written for PRB by Drew Thompson: