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close this bookDrug Use and HIV Vulnerability (UNAIDS, 2001, 238 p.)
close this folderChapter 2: People's Republic of China
View the documentI. Summary of findings
View the documentII. Recommendations
View the documentIII. Introduction
Open this folder and view contentsIV. Findings
Open this folder and view contentsV. Discussion

I. Summary of findings

China's experience with large scale opium addiction prior to the establishment of the People's Republic in 1949 has resulted in it's determination to be a drug free society.

Few activities other than a small number of 'pilot projects' are at present specifically targeted at reducing the risks of HIV/AIDS among injecting drug users.

Very few such approaches designed specifically to reduce the harm from injecting drug use are favoured in China at present.

The responsibility for drug treatment is shared between the Ministry of Public Security and the Ministry of Public Health. Each brings a different perspective to the problems of drug treatment but neither is supportive of strategies targeted specifically at reducing the risk of HIV infection among injecting drug users.

Methadone can legally be used only for medical purposes. Some treatment facilities run by the Ministry of Public Health use methadone for detoxification. Extending its use is generally regarded as inappropriate and expensive.

Needle and syringe exchange or distribution is generally seen as redundant.

Although the government ministries in Beijing provide guidelines and assistance in strategic planning, budgets and activities are determined on the provincial, district and commune level and can thus be responsive to local need. This provides the opportunity of matching interventions to local needs.

Pilot projects are generally welcomed in China and can be used to demonstrate usefulness and efficacy if properly monitored and evaluated. So far they are rarely if ever expended or sustained after the end of the pilot.

Out-reach and peer led activities are acceptable and could be extended if funding and training are made available.

II. Recommendations

UNAIDS can play a role in consensus building by resolving some of the conflicting aims and priorities within key agencies (e.g. the Ministry of Health, the Ministry of Public Security, the National AIDS Programme, UNAIDS, UNDCP etc.).

UNDCP's co-sponsoring of UNAIDS provides the opportunity for joint programming where HIV infection among injecting drug users is occurring.

Chinese scientists could be encouraged to develop culturally acceptable approaches to reduce the risks of HIV infection among injecting drug users.

Community based approaches that include community mobilisation and community support for relapse prevention are acceptable and should be developed.

Special attention should be given to making these approaches relevant to the HIV/AIDS epidemic.

Out-reach and peer education activities should be developed to include information on needle sharing and sexual transmission.

Consideration should be given to needle and syringe distribution (or exchange) and condom distribution.

Chinese authorities should give urgent attention to developing programmes in provinces where HIV prevalence among injecting drug users is still low.

Much could be done to improve the existing treatment and rehabilitation services for drug users in China. Shorter, non-institutional treatments should be considered along with more effective relapse prevention and rehabilitation.

Training in the fundamental concepts of addiction would be useful to the treatment community. Often casual and occasional users are confused with drug dependent individuals.

China should also give consideration to developing further its alcohol policies to include education on safe drinking limits and the effects of uncontrolled drinking. Heavy drinking is a feature of many social gathering in China and can thus prove to be a serious risk factor for unsafe sex and the transmission of HIV.

III. Introduction

When the People's Republic of China was established in 1949 there were some 20 million opium users in China. At the beginning of 1950, the Government Administration Council issued the order prohibiting the taking of opium. This led to a nation-wide drug prohibition campaign. Opium and other dangerous drugs were confiscated, the growing of opium was prohibited, opium dens were closed, drug users were rehabilitated and people growing opium or trafficking in drugs were severely punished. Over 369,700 people who were involved in drug production or trafficking were rounded up and punished and thousands of drug users were treated of their addiction. China was able to maintain a drug free status for the next 30 years (Zhang Chongde and Chen Yuan, 1998).

Drugs began to re-emerge as a problem in the early 1980s but China adopted a vigorous and resolute policy to fight drug use a policy which, is profoundly determined by China's previous experience of large-scale opium addiction.

The HIV/AIDS epidemic in China that emerged in the 1990s is closely linked to injecting drug use. As in other countries in the East Asia region (notably Thailand and Myanmar) the epidemic seems to have been 'jump-started' by drug users and although the epidemic is spreading to other groups they still represent the largest numbers of infected individuals in China. It is critical therefore to examine strategies in China that straddle these two overlapping issues.

A. Epidemiology of drug use

Drug trafficking and drug use began to re-emerge in the early 1980s and there has been a steady increase in the numbers of illicit drug users ever since. At first identified drug use was localized in border areas with Myanmar particularly in Yunnan province and was practised mostly among minority groups. From the mid 1980s the numbers of drug users began to spread inland. Drug use has since spread to as many as 1924 counties in China. The emergent drug use patterns vary from region to region but general trends suggest a move from opium smoking to heroin that is either smoked or increasingly used by injecting. Official information provided by the National Narcotics Control Commission (NNCC) is described in Table 2.1.

However, the true extent of illicit drug use is difficult to determine. Drug use is severely punished and is likely therefore to be kept secret and furtive as much as possible. Moreover the system used to collect official data which result in registration does not adequately reflect the real situation. (See note on data gathering in later section).

Nevertheless there is evidence that the majority of registered drug users (about 80%) are young and male and that an estimated 2/3 of them inject drugs (Source: NNC Bureau briefing). It is noteworthy, however, that in a report comparing the drug use situation between 1993 and 1997 in Wuhan, the ratio of female drug users had increased from 18.5% to 35.8%. Research evidence about injection use is somewhat more equivocal and reflects some regional and temporal differences but suggests that the transition from smoking to injecting is rising in most sites. The sharing of needle and syringes has been reported to be commonplace in various parts of China and re-usable glass syringes are most frequently used with varying attention to sterilization. In many parts of China disposable needles and syringes can be obtained easily and cheaply (1 Yuan). However, in some regions particularly in remote areas needle and syringes are not easily obtained and drug users have been known to use home made paraphernalia.

Table 2.1 Number of registered drug users in China

Year

Number of registered drug users

1990

70,000

1991

148,000

1992

250,000

1994

380,000

1997

540,000

Source: China's Battle against Narcotics

In Yunnan, Xinjiang, and Guangxi there are high numbers of heroin users while in Neimenggu (Inner Mongolia), Ninxia autonomous Region, Qinghai and Hebei there is a greater proportion of opium smokers.1

1 China responds to AIDS: HIV/AIDs situation and Needs Assessment Report. Ministry of Health with UN Theme group on HIV/AIDS in China Nov. 1997

B. Mechanisms for drug control

China's legal framework for drug control was formulated in 1979 and was part of the Criminal Law. It imposed severe punishments for the manufacture, trafficking and supply of illicit drugs. Ten years later, the State Council of the People's Republic of China promulgated the Procedures for Narcotic Drugs Control (in 1987) and the Procedures for Psychotropic Substances Control (1988). The Decision of the Standing Committee of the National People's congress on the Prohibition Against Narcotic Drugs, which was adopted at the 17th meeting of the Standing Committee of the 7th National People's Congress in December, 1990 set out the regulations and penalties for drug trafficking, possession and use. It specifies the following in Section 8.

Whosoever ingests or injects narcotic drugs shall be punished by the public security organ with detention of not more than fifteen days, and may simply or concurrently be punished with a fine of not more than 2,000 yuan, and the narcotic drugs and the instruments used for drug ingestion or injection shall concurrently be confiscated.

Whosoever addicted to drug ingestion or injection shall, in addition to being punished as provided in the preceding paragraph, be forced to quit the addiction and be subjected to treatment and education. Persons who ingest or inject narcotic drugs again after being forced to quit may be subjected to rehabilitation through labour and shall be forced to quit during the period.

The National Narcotics Control Commission (NNCC) was established in 1990 by the State Council and consists of personnel from 23 governmental and mass organizations. Its role is to provide a unified leadership for narcotic control, to coordinate the efforts to solve major problems and to formulate principles and policies. Executive organs for narcotic control were also established in all provinces, municipalities and autonomous regions in China directly under the central government.

In 1998 after the First Session of the 9th National People's Congress, the Ministry of Public Security was empowered to assume overall leadership for China's narcotics control under the direct leadership of the State Council.

The essence of China's drug policy is as follows:

'Prohibiting trading in drugs, taking narcotic and planing poppies simultaneously, eradicating sources of drugs and obstructing channels of trafficking, enforcing the law strictly and solving the problem by examining both the root causes and its symptoms' (NNCC)

Possession of drugs is severely punished e.g. the possession of 50 grams of heroin or 1000 grams of opium can result in imprisonment of not less than seven years or life imprisonment. Those who smuggle, traffics in, transports or manufactures narcotic drugs incurs heavy penalties and may under certain conditions be sentenced to death (Decision of the Standing Committee of the National People's Congress, 1990).

In January of 1995 the State Council promulgated the Procedures for Compulsory Drug Addiction Rehabilitation. According to the regulations, drug users are made to receive medical and psychological treatment as well as education in China's legal system and public ethics until their addiction is cured. China has clearly articulated policies on drug use. These can be summarized as follows:

“To check the increase of drug addiction, effectively and thereby eradicate drug-related crimes, the Chinese government will improve and strictly implement various measures in accordance with the regulations of the Procedures for Compulsory Drug Addiction Rehabilitation formulated by the State Council; all addicts will be forced to undergo treatment. Those who relapse will be sentenced to re-education through labour. For those who have given up drug addiction, the work to keep them healthy both physically and mentally must be done well”.

From: China's Battle Against Narcotics (1998)

The government's policy is to actively rehabilitate drug users. It is the duty of the local government to organize Public Security, Judicial, Civil and Public Health Departments to carry out the work of compulsory rehabilitation. The process of compulsion varies and depends on the local authorities and the public security personnel. Those detained by officers of the Ministry of Public Security on suspicion of drug use are first persuaded to come off drugs in their own homes under supervision by the police. Alternatively they are encouraged to enter voluntary treatment in one of the facilities run by the Ministry of Health. But, when this persuasion and voluntary measures fails, drug users are invariably sent to compulsory centres. The judicial treatment centres are used for those who have committed offences (in addition to using drugs).

C. Drug treatment

By the end of 1997, 695 compulsory treatment centres had been established consisting of 77,000 beds at which 183,000 drug users had been treated. In addition there are 86 treatment and rehabilitation centres through labour to which so far 210,000 drug users had been admitted (NNCC briefing). Altogether China has quadrupled its capacity to treat drug users in the last 5 years. At compulsory treatment facilities symptomatic treatment is provided for detoxification using both western and traditional Chinese medicines. The compulsory treatment generally lasts between 3-6 months but may be as long as one year.

The role of Health Services

Following the restructuring of government departments the responsibility for this matter has been given to a newly established department the State Drug Administration (SDA) which has been likened in China to the US Federal Drug Administration. This is an independent department, established in October 1998, which works in collaboration with the Ministry of Health but is not part of it. Not all its functions have as yet been determined. That means that they have wide ranging responsibilities for food safety and for the approval of drugs for use in China including the treatment of illicit drug users. The Ministry of Health is only involved to the extent that some of the treatment centres are situated within hospitals run by the Ministry.

There are over one hundred treatment facilities managed by the SDA treating some 10,000 patients every year. These are closed units located within Psychiatric Hospitals, which means that although entry to treatment is voluntary the treatment itself is compulsory; once a drug user enters the treatment unit she/he signs an agreement that she/he will not leave until treatment is completed. Thus the voluntary treatment centres collaborate closely with the public security departments. Treatment in voluntary establishment has to be paid for by the patients and the cost varies from about 2000-5000 Yuan per treatment and is a considerable sum relative to average income. A variety of drugs are used in the voluntary treatment centres, many of which are Chinese herbal medicines. There is a great deal of work in the scientific research community to develop better drugs for detoxification using local herbs and traditional methods (including acupuncture). Research is also focused on drugs that may be used to prevent relapse and to deal with the longer-term consequences of detoxification such as chronic insomnia. It is noteworthy that some of the more promising herbal medicines have been found to be too expensive for general use.

Methadone

Some voluntary treatment centres use methadone for detoxification but its use is strictly regulated. Methadone treatment was the responsibility of the Ministry of Health and now of the SDA and it is for them to determine its use. However, because the Ministry of Public Security has been given a lead role in drug control, any change in use has to be discussed and approved for by the Ministry of Public Security and its drug control organ the NNCC. At present the medical use of methadone is regulated by the Narcotics Drug Control Act, which stipulates that:

“The use of narcotic drugs is restricted to medical treatment, education and scientific research. Medical units equipped with beds, capable of performing operation or those considered to be qualified may apply for a 'Narcotic Drug Purchasing Card”

Article 31 of the Narcotics Drug Control Act

In practice this means that methadone can only be used in approved medical inpatient facilities and restricted to medical treatment. It is the understanding of medical authorities that maintenance (longer-term treatment which does not treat the symptoms of detoxification) is thereby prohibited.

Treatment in voluntary facilities managed by the health authorities lasts no less than one month and up to three months and in general some drugs will be prescribed to assist patients to detoxify for the first 21 days. Patients have to pay for treatment, which is expensive, and the health authorities lack the financial and human resources to extend the service (e.g. to replace or augment the compulsory treatment centres). The doses of drugs prescribed to assist detoxification vary and depend on the needs of the patient. The SDA is exploring the possibilities of prescribing some Chinese medicines after discharge to help prevent relapse.

Treatment Outcomes

There is no systematic follow up data available for either the compulsory or the voluntary treatment system, but by all accounts (Ministry of Health, NNCC) relapse rates are very high and are estimated to range from 60-90%.

China cites one example of a successful programme to create a drug-free city. The account of the successful eradication of drug use in Baotou is illustrative of the Chinese vision of what should be done in the country to deal with drug use.

Baotou - Inner Mongolia Autonomous Region

It is a city of some 2 millions which had a very serious drug problem before 1949. Drug problems re-emerged in the 1980s and 90s. In 1990 there were just 69 drug users in Baotou but a year later the numbers of users increased to 1894 and by May 1999 - 3730 drug users had been registered in the town. When users are first identified they are immediately sent to the city's compulsory treatment centre and if they relapsed are sent to a Labour Correction camp. So far 1023 have been treated in the compulsory treatment centre, which opened in 1997, and a further 2221 have undergone Labour Correction treatment. Altogether after treatment 740 have remained drug free for 3+ years and 751 have been off drugs for 1-3 years and 609 for less than one year. In June 1999, 1115 were in the process of being treated in one of the two facilities in the city. The city has already achieved drug - free community status in 76% of the city.

The reasons for this success are said to be the multi-sectoral approach, which is led by public security with the participation of community organizations (Street Committees, Watchdog Committees, the police, Care - Young people's Association, the Women's Federation and the Youth League). Recovering drug users are place in a social assistance programme that ensures that the above organizations provide ongoing support and supervision to ex-users. Furthermore, the city has set up a system of rewards and punishments for the police to encourage them to apprehend all drug users. Members of the community are also encouraged to inform on suspected traffickers and drug users.

This experiment is considered to be a model for the whole nation and leaves little doubt that interventions other than those with an abstinence goal will have scant appeal in China at the moment.

Relatively little progress has been made in China in efforts to rehabilitate drug users following detoxification. One exception may be the therapeutic community (Daytop) which has been established in Yunnan Province.

D. HIV/AIDS

General information

China is undergoing major social and economic changes and has been increasingly open to trade and economic ties with countries in Asia and elsewhere. This opening up has facilitated the gradual spread of HIV/AIDS among the general population. The HIV/AIDS epidemic in China can be seen to have gone through three distinct phases. During phase one (1985-1988) just 7 provinces reported HIV/AIDS infections and all cases were among foreigners or overseas Chinese. During the second phase of the epidemic (1989-1993) HIV/AIDS spread to 21 provinces and most cases reported from the provinces were along the coast and from big cities. HIV was also identified among drug users in Yunnan province limited geographically to the southern areas of Yunnan Province bordering Myanmar. The period between 1994-1998 saw a rapid expansion of the epidemic spreading to 31 provinces, municipalities and autonomous regions in China and to have spread from a concentration among the minorities to the majority Han population and to be increasingly transmitted sexually.

The true extent of the epidemic in China is difficult to determine because of insufficient information. Although the numbers of infections appear to be rather small for a country the size of China, the National Programme for the Prevention and Control of AIDS estimated in December 1998 that there may be more than 400,000 HIV infected people in China2. Sentinel surveillance began in 1995 when 42 HIV sentinel sites were selected throughout China and the number of sentinel sites rose to 60 in 1997. The population groups that were defined as targets at the sentinel sites include: drug users, commercial sex workers (CSW), long distance truck drivers, ante-natal clinics, blood donors and male patients in clinics for sexually transmitted diseases (STDs). Not all groups are represented at each site. IDUs are tested in 19 sentinel sites in 16 provinces. Thus, although the surveillance reflects trends in HIV infection it is does not adequately inform about the size of the problem. The available data on HIV is currently derived from all sources including the sentinel survey (Table 2.2) and information about HIV cases identified in medical establishments3. HIV is a notifiable disease and the records are kept in the health sector and are anonymous.

2 UNAIDS country profile - March 1999

3 Reported cumulative AIDS cases - 439 (31st December 1998) of whom 224 have already died. Reported cumulative HIV+ cases - 12,580 (31st December 1998) UNAIDS country profile - March 1999

Little voluntary testing takes place and pre- and post counselling is in short supply. There is a general reluctance to test drug users in either treatment or rehabilitation centres (except for the anonymous unlinked testing of the sentinel surveillance). This is because those found to be HIV positive are immediately discharged in accordance with a regulation jointly issued by the Ministry of Public Security, Ministry of Justice and the Supreme Court. There is also a reluctance to inform people of their status because of the fear that patients will commit suicide.

Yunnan remains the province with the highest number of infections and accounts for 51% of all infections in China (September 1998). As can be seen on Table 2.3, the modes of HIV/AIDS transmission in China are sharing of needles among IDUs, unsafe sexual practices, unsafe blood transfusions and unsafe homosexual activities in some cities. Thus the populations most vulnerable to HIV infection are drug users, STD patients, migrants, ethnic minorities and commercial sex workers. By 1998, 69.4% of all detected HIV cases were as a result of drug injection.

Table 2.2 Reported HIV/AIDS cases from 1985-1998

Year

Total

HIV

AIDS

1985

5

4

1

1986

1

1

0

1987

9

7

2

1988

7

7

0

1989

171

171

0

1990

299

297

2

1991

216

213

3

1992

261

256

5

1993

274

251

23

1994

531

502

29

1995

1567

1515

52

1996

2649

2611

38

1997

3343

3217

126

1998

3906

3170

136

Total

12639

12222

417

Source: Sentinel surveillance, Division of Disease Control, Ministry of Health

Table 2.3 HIV/AIDS transmission categories 1985-1998

Transmission risk factor

Total

%

HIV

AIDS

Homosexual

18

0.13

10

8

IDUs

8776

69.4

8575

201

Heterosexual

816

6.5

711

105

Blood products

35

0.3

30

5

Mother to child

9

0.07

7

2

Other

2985

23.6

2889

96

Total

12639

100

12222

417

Source: Sentinel surveillance, Division of Disease Control, Ministry of Health

The majority of those infected by HIV are male (81.9%). It is worth noting incidentally, that STDs have increased considerably in China in the last few years and now rank as 3rd among all infectious diseases in China (after dysentery and hepatitis).

HIV among injecting drug users

Drug users engage in high-risk behaviours and were the first to be infected with the HIV in China and most new cases (70%) are related to sharing needles among injecting drug users. To-date they represent the largest category of infected people. In 16 provinces HIV was identified among drug users. However, in a recent study conducted by the Ministry of Health (Department of Disease Control) jointly with the Ministry of Public Security among drug users in 9 provinces; 6000 drug users were tested for HIV (800 in each province 50% of the total were IDUs). The results indicated that there were very low rates of HIV infections (about 1%) in 8 of the provinces and no HIV infections in one of the 9 provinces.

Yunnan Province

HIV infections were first identified in Yunnan in 1989. A survey conducted between 1992-4 in Dehong prefecture in Yunnan on the border with Myanmar revealed that more than 30% of drug users were injecting and that between 70-80% of them were sharing injecting equipment.

Altogether 5678 infections have been reported in Yunnan province and 89% of these are among injecting drug users. The highest prevalence of HIV is among young people aged between 15-30 and as many as 14% are amongst women. In the last few years there has also been a notable shift from infections among the minority population to the Han population and from the rural into the urban areas. Prospective data from Yunnan province indicates that infection rates of spouses of IDUs was increasing and rose from 3% in 1990 to 12% in 1996.

There are also well documented epidemics among IDUs in the provinces of Xinjiang, Sichuan and Guangxi.

Xinjiang Autonomous Region

In Xinjiang drug use has markedly increased in 1996 with 50-80% of drug users injecting by December 1997 of whom 17% were infected with HIV. HIV rates had doubled in a six-month period.

In Ili prefecture, HIV among tested injecting drug users increased from 9% in January 1996 to 76% in August of the same year.

In Yiling city the rates of reported HIV among drug users rose from 26% in 1995 to 49% in 1996 and rose to 70% in 1997 (Zunyon Wu and Zhang Jiapeng 1998).

It should be noted that the rate of condom use among IDUs in Yiling city among IDUs is less than 1% (Ref: China Responds to HIV/AIDS).

Altogether 1615 cases of infection have been reported, estimates of HIV infected IDUs are considerably higher.

Sichuan Province

An HIV epidemic has been identified among the Yi minority (figures not available) especially in the Liangshan prefecture, on the Kunming-Chengdu main road which is also the main trafficking route from Myanmar through China. A study conducted in 1995 among drug users showed that 35% of those tested were HIV positive.

Guangxi Autonomous Region

About 90% of drug users inject drugs. Reported cases of HIV infection from Baishi City rose from 0.43 in 1996 to 77.2% a year later. (Zunyon Wu and Zhang Jiapeng 1998)

Hepatitis C infections among opioid users are believed to be as high as 80% among certain populations.

E. Prevention and control of HIV/AIDS

The control of HIV/AIDS

Since the establishment of the People's Republic of China in 1949 China has successfully controlled a number of communicable diseases such as smallpox, diphtheria, typhus, cholera and plague with highly effective public health measures. However, HIV/AIDS is the kind of infection that does not easily lend itself to conventional public health measures such as testing, reporting or isolation. This is because HIV is often spread amongst marginalized or stigmatized groups through behaviours that are essentially private. (Ren-Zong Qui 1996). China's efforts to control the spread of HIV/AIDS began formally only one year after the first case of HIV was identified in 1985. Thus the National AIDS committee was established in 1986 and the Programme for AIDS Prevention and Control was established in 1987.

In March 1990 the Chinese Ministry of Health adopted a medium term plan in line with global policies. This plan was divided into a comprehensive national plan and included in addition 13 plans for selected provinces. In 1995 a new National AIDS Committee was established consisting of 33 ministries, government and non-government agencies and hosted by the State Council and the budget for the National AIDS Programme rose sharply for 1996-7. Indeed in 1996 State Councillor Peng Peiyun declared that:

'The Government has placed AIDS prevention and control among the priorities of the Ninth Five-Year Plan and China's Twenty-First Century Agenda' (October, 1996)

Nevertheless, in its Medium and Long-term programme prepared for the years 1998-2010 by the Ministry of Health, State Development Planning Commission, Ministry of Science and Technology and Ministry of Finance, are highly critical of China's current efforts in HIV/AIDS control. It comments that China's capacity to deal with the problem is inadequate, that a functioning multi-sectoral and co-ordinated approach is yet to be created. It notes incidentally that the understanding of the issues among some leaders is insufficient. The programme further highlights the fact that to-date there is a lack of knowledge, research, medical and health services and surveillance and a weak management of blood safety. However the report expresses the objectives that:

'By the year 2002 relevant laws, legislation and regulations relating to the prevention and control of AIDS and STD are to be formulated and perfected, responsibilities of governmental departments and social sectors concerned in the control of AIDS as well as rights and obligations of AIDS... to be defined'

(p. 9 of Medium and Long Term Plan)

The operational objectives of the programme include the implementation of education activities on the prevention of AIDS and STD in 100% of the rehabilitation and detention and education centres and in 80% of the prisons and reformatories by the year 2002. Moreover, it is planned to step up 'legal education on the banning of drug abuse and prostitution among high-risk population groups, to urge them to change their wrong behaviours. Use of condoms is to be encouraged, education on the harmful effects of sharing a syringe is to be developed' (Medium and Long Term plan 1998-2010). The overriding objective is to contain the spread of HIV/AIDS among IDUs by the year 2002.

The Department of Disease Control at the Ministry of Health is the focal point of China's AIDS effort and the Ministry is responsible for the development and implementation of the plan.

Risk reduction: acceptable interventions

'What is needed in addition to efforts to reduce both the supply of and the demand for drugs, is a forceful effort at reducing the harmful consequences of drug use, in particular educating injecting drug users about the dangers of sharing needles and of the health risks associated with using unsterilized needles in general'

(China Responds to AIDS. China Ministry of Health and UN Theme Group on HIV/AIDS in China. p. 11)

The importance of reducing the risks for drug injectors of contracting HIV are accepted and understood in China, and have been clearly articulated in the National AIDS Plan as an objective to be reached by the year 2002.

Educating people to say 'No' to drugs is a fundamental part of China's drug policy hence the emphasis placed on education and publicity. China has launched an intensive programme of preventive education, and much work is going into raising awareness about the dangers of drugs. In order to promote drug education among teenagers a book titled 'A textbook of narcotics control education and narcotics prevention education' has been distributed among middle-school students as their extracurricular readings and TV documentaries have been produced to deliver information about the harms of drugs. A major anti-drug exhibition was organized in 1998 in Beijing and one and a half million people including the country's leaders visited it. The exhibition was shown subsequently shown in many other parts of China and altogether an estimated 160 million people saw the exhibition.

Peer education/outreach is the most acceptable form of intervention as is the provision of information about the safe use of needles and syringes - this was emphasised as the major vision for the future. Some pilot projects targeting specific risk behaviours are being implemented or are at the planning stage.

Views on other types of intervention

Many in China do not favour certain interventions that are commonly used elsewhere in the attempt to prevent the spread of HIV/AIDS among drug injectors.

Needle distribution of exchange schemes

There appears to be little or no support for this. It was generally asserted that needles are easily and cheaply available. The cost is approximately one Yuan (8 Yuan = $1). No one saw much point to delivering free equipment when the health service is starved of clean and sterile equipment. However, there were areas, most especially in border regions where needle and syringes were by no means easily available.

Substitution therapy

The view of many scientists in China is that such treatments should be more easily available. Scientists and the NNCC are aware of the usefulness of methadone in other countries most especially as a measure for HIV/AIDS prevention among IDUs. An Expert Committee chaired by Prof. Cai-Zhi Ji of the National Institute on Drug Dependence at the Beijing Medical University suggested that methadone be used experimentally (in pilot projects) and that the detoxification period should be prolonged. However, few go as far as to recommend maintenance. There is little conviction that where prevention of HIV are said to be successful that it can really be attributed to this one intervention.

Methadone for the purposes of detoxification was generally viewed positively though many felt that Chinese medicines might be more appropriate and perhaps more acceptable. The question of competing priorities and the general problems within the health service was repeatedly brought up.

Giving the wrong message using an opiate to treat opiate addiction was considered by many to be a contradiction in terms. China is firmly wedded to the notion of drug use elimination, and despite the evidence of high relapse and treatment failure rate are not willing to consider anything other than an abstinence goal for drug treatment.

At present the use of methadone is highly regulated (see Narcotic Drug Control Act). Thus the Ministry of Health is constrained by these legal obligations and cannot provide methadone in the context of ambulatory treatment nor in any other than 'medical treatment' of the (physical-medical) symptoms of addiction.

Many drug users in China live in rural areas and have limited access to treatment facilities. It was considered impractical to have large-scale methadone programmes while addicts cannot be expected to attend a clinic daily.

A. Constraining factors

Administrative changes: China has been undergoing administrative reforms and far reaching changes began to be implemented in October 1998. Ministries at the central level in Beijing have been considerably downsized. (e.g. the Ministry of Health has only approximately 200 staff in Beijing). Very little funding is available from the central government for interventions though some small pilot projects are occasionally funded. Local provincial, prefecture and commune level have to obtain their own revenues and implement their own activities. China is a politically and administratively de-centralized country thus the implementation of laws and directives is largely dependent on the local situation and on local interest and budget.

Policy and strategy: The major responsibilities of ministries on the central level is policy and strategy development and the provision of guidelines for action to provincial and other local bodies. The role of the provincial authorities is tactical and strategic as they translate central government guidelines to local conditions. There is local flexibility in how the general guidelines are operated. It is important to note that local level activities depend largely on availability of resources and on the priorities set by top local officials. For the implementation of drug policy, much depends on the relationships between different sectors in the community e.g. health and the local narcotic control authorities. This decentralised system provides an opportunity for local community based actions although it is generally understood that once the central government favours a policy, the regions will generally comply.

Whose responsibility is Drug and HIV prevention? The NNCC believe that the responsibility for preventing the risk of HIV/AIDS among drug users is the responsibility of the Ministry of Health and that methadone could be part of detoxification if the Ministry of Health chooses to introduce this into the voluntary treatment system. However, the relevant department in the Health Ministry (now the State Drug Administration) notes that any change in drug treatment needs to be approved and sanctioned by the NNCC, which has the lead role in China in drug control. Asked whether they would like the sole responsibility for drug treatment the SDA retorted that they had no capacity to undertake such a role. Respondents within the health sector did not feel that the system of treatment as it stands needed immediate or radical change.

Evidence-based drug and HIV prevention policy: China has many research facilities and a long tradition in drug research but the focus of study has been on two major issues: the improvement of detoxification technologies, and on epidemiological surveys (e.g. determining HIV status among users). China has not yet conducted systematic post-treatment or rehabilitation follow-up studies so there is scant information on whether the very extensive rehabilitation efforts are having the desired benefits.

There do not seem to be mechanisms in place, which would facilitate policy, reviews in the drug field and very little inclination, to change course. The conviction that China must strive towards a drug-free society at all cost prevails. Very few are clear about how policy can in fact be changed or reviewed. Most of those working in the drug and HIV field have very little notion about how to bring about change in thinking though there is little doubt that the power to change lies firmly in the hands of senior personnel within the Ministry of Public Security.

B. Estimating the size of the drug problem: data gathering

It is unclear how drug use/addiction is defined in China. Much of the information about use comes from the families of the users and the local community and passed on to the Ministry of Public Security. There is little doubt that because the penalties for use are severe that user try to hide their use for as long as possible. There are varying estimates about the true extent of drug use and these may be considerably higher than the numbers of registered users.

Information about drug use is collected in a number of different ways. The two major methods are as follows:

(a) Local police operating on a commune level provides information to the Ministry of Public Security. Police officers visit every household but it is not clear how often as the staffing level of public security on the commune level is rather small. Theoretically the figures are continuously updated. Those currently in treatment or in rehabilitation are also included in the figures (may be double counted because information is also gathered from the treatment centres). Once a drug user is identified the information is passed on from the commune to the prefecture and provincial authorities. In practice it is not clear how/whether this information is updated or whether anyone ever gets off the record. There is no specific information about the mode of drug administration so it is not clear how many of the known/registered drug users are drug injectors.

(b) The health sector has its own recording system. The ministry has a computerised database in 16 provinces. All admissions to the voluntary drug-treatment centres run by the Ministry of Health (now the SDA) are recorded. These figures reflect the number of admissions and not the number of patients. However the patients are also counted and registered under the Public Security system.