Consistent with previous findings in both international[25–30] and Chinese settings[21–23], our findings indicate that provision of clean needle/syringes does not increase the injecting frequency among IDUs, and furthermore that increased availability of clean needles/syringes may substantially contribute to the reduction in repeated use of dull syringes and sharing activities among Chinese IDUs. Liu et.al., in 2007, demonstrate that the rate of syringe sharing in the past 30 days among IDUs who regularly attend NSPs (15%) is two to three times lower than non-attendees (32-44%) in Guangxi and Sichuan provinces. Wu et.al., through a 12-month cohort study, show that the sharing rate dropped from 68% to 35% in the NSP intervention community in South China. Although, in comparison, IDUs in Hunan have a much lower sharing rate in general (low-access group: 16.3%), an increased ability to access NSPs is associated with substantial reductions in sharing behaviors (high-access group: 2.5%).
IDU recruits from MDCs exhibit significantly higher sharing rates, indicating a higher level of risk behaviors. Lower ability to access NSPs prior to their incarceration also suggests that the participation in MMT and likely police supervision may have prevented IDUs from accessing NSPs. In contrast, approximately two-thirds of the community and NSP recruits obtained more than 80% of their syringes from NSPs, suggesting NSPs are generally available and accessible to the majority of IDUs outside of the detention settings. In addition, confinement in MDCs does not reduce drug use behaviors[31–33] and as high as 95% of IDUs relapse for drug addiction within one year of release. Detainees also have limited access to health information and education that are often associated with NSPs. Together with our findings, this indicates that mandatory detoxification may be a major obstacle for harm reduction programs and improving risk behaviors for Chinese IDUs.
The first major limitation of this study is its cross-sectional design. This does not enable us to directly investigate the causal relationship between NSP accessibility and its direct impact on drug use behaviors, although it provides an association analysis between the two. Second, the ability to access NSPs is defined as the self-reported percentage of acquired NSPs syringes in the past three months, which may be subjected to self-recall bias. Third, although the study has been carefully designed to obtain information of injecting behaviors of recent MDC entrants prior to their admittance, the information may underestimate their actual risk behaviors due to prior harm reduction programs (e.g. MMT)[35, 36] and the temporary abstinence of injecting behaviors during the transferring process to MDCs by the police.
Our study has clearly demonstrated behavioral improvements when the ability to access NSPs increases in China. In addition, NSPs have been shown to be highly cost-effective in both international[37–40] and Chinese settings. Full scale roll-out of NSPs should be implemented as a major component of harm reduction strategies nationwide. However, continued law enforcement and mandatory detoxification remain as major barriers to the necessary program scale-up and may even counteract the benefits of NSPs[11, 42]. Ongoing police crackdowns, arrests and confinement substantially discourage IDUs from contacting peer health educators and accessing NSP sites. In comparison, in places where police are supportive of NSPs, coverage of the programs quickly increased and risk behaviors decreased. Without effective cooperation between legislation, law enforcement and health policy sectors, NSPs are unlikely to reach a sufficient proportion of IDUs to make a significant impact on China’s HIV epidemic.