Whether or not China can shun a generalized epidemic of HIV/AIDS may be largely dependent on how China deals with IDU risk factors and breaks the bridge between IDU and heterosexual transmission. Past experience in China suggests that solely cracking down on drug smuggling and prohibiting drug use can not prevent or solve all illicit drug related problems in the era of globalization. Governmental support, harm reduction programs, voluntary counseling and testing, and utilization of non-governmental organizations are recommended.
Strengthening government's leadership at both central and local levels
China has a strong central government. Without government support, it would be not imaginable to achieve success in the campaigns against drug use and the spread of HIV/AIDS. Since the late 1990s, the Chinese central government has stepped up HIV/AIDS control efforts, including setting out national policy framework for responding to HIV/AIDS, increasing funding inputs, expanding collaborations with international organizations. The Chinese National Medium-and-Long-Term Strategic Plan for AIDS Prevention and Control (1998–2010) was formulated in 1998 and set one goal that "by 2002, health education on preventing HIV/AIDS and STDs should be carried out at all detoxification centers and re-education centers as well as in 80% of jails..." . The Action Plan (2001–2005) calls for creating "drug-free communities" through drug prohibition education and drug detoxification activities, together with active promotion of healthy life styles and behaviors and harm reduction for drug users.
On the other hand, there is substantial autonomy at provincial level in some areas. Responses to drug use and HIV/AIDS epidemic vary significantly at provincial and lower administrative levels. For example, Yunnan and Guangxi provinces have done far more than other provinces in supporting, implementing, and advocating for harm reduction interventions for IDUs. Some local governments are not fully motivated to confront drug abuse and HIV/AIDS problems. Some government leaders still ignore or even cover up these problems. They are far more interested in economic growth than HIV/AIDS control and wish for their administrative areas to become "economy provinces" or "economy cities" rather than "AIDS provinces" or "AIDS cities," which is believed to be helpful for their career promotion. Advocacy to and support from government leaders at all administrative levels for harm reduction and community-based prevention are needed.
Scaling up methadone substitution and needle exchange programs
Harm reduction includes many strategies, such as methadone maintenance, needle exchange, dispensing other drugs, and outreach services . Harm reduction has been a controversial issue as compared to abstinence-based philosophies [39, 40]. Harm reduction seems to encourage tolerance of social phenomena that are undesirable and hazardous and that may result in social turpitude. Instead, abstinence is considered to be the proper way to address drug problems . In the United States, law and policy restrict the use of federal funds in supporting needle and injection equipment distribution projects. However, many studies refute the concern that access to sterile syringes is an endorsement of IDU and is likely to result in increases in injection and initiation of injection [41, 42]. Harm reduction projects in China are in the pilot phases. Some scholars and health officials still have similar concerns as in some Western countries. They believe that needle exchange services may send a wrong signal of encouraging drug abuse to drug users and the public, and they consider methadone substitution unethical because it uses one drug to replace another drug . As drug use and HIV/AIDS spread rapidly across the country, it is urgent to find supporting domestic evidence that harm reduction will reduce HIV transmission by evaluating harm reduction projects and ultimately scaling up harm reduction efforts.
It is easy to access sterile needles and syringes in urban areas of China because they are legally sold and available at pharmacies and medical clinics [16, 44]. However, many drug users live in rural areas; in addition, drug users may share needles and syringes because they can not buy them during night time or do not have money to buy them . Methadone is orally administered, and methadone substitution can reduce injection and needle sharing of opiate drug addicts. But methadone maintenance therapy is costly and requires drug users to attend clinics on a regular basis. Therefore, methadone substitution and needle exchange services should be made available and affordable at convenient times and in both urban and rural settings, especially in the communities with heavy drug use.
In addition to cost and availability, other factors might also affect acceptability of methadone maintenance therapy, such as concerns about the safety and efficacy of the therapy . Greater retention in treatment has been found to result in greater decreases in drug use, criminal activity, and unemployment . The length of drug treatment has a positive association with better post-treatment outcome . However, limited experience with methadone maintenance therapy (MMT) in China shows a high rate of dropouts. International studies have shown that motivational enhancement therapy or motivational interviewing enhances treatment initiation, retention and outcomes in MMT program [47, 48], and adding behavioral intervention components into MMT programs increases abstinence and reduces HIV risk behaviors . Policy-oriented operational research is needed in China to better understand how to increase the effectiveness of MMT and other harm reduction interventions in the Chinese context.
There are still persistent conflicts in the policy and legal landscape. The central government has given explicit support to harm reduction, for example, as stated in the Medium- and Long-Term Strategic Plan and the Action Plan. Some programs have been implemented successfully [36, 50, 51]. However, in China, as in many other countries, public health and public security authorities frequently approach drug abuse from different perspectives, leading to conflicting approaches at local levels. The crackdown philosophy and detention of drug users in China reflect inconsistent interpretations of "harm reduction" and present a challenge to public health officials in implementing methadone substitution and needle-exchange programs . Drug users may be reluctant to participate in these programs due to fear of being caught by police officers . It might be impossible to completely solve the dilemma in the near future, but this conflict is expected to gradually reduce for the following reasons. First, Chinese national policies for HIV prevention and control have become much more pragmatic in the past years. MMT and needle exchange programs were almost unimaginable several years ago, but now they are ready to be expanded across the country. We expect that the open policy trend will continue as the Chinese economy is increasingly merged with international markets, and this trend will favor harm reduction programs. Furthermore, China's centralized government may achieve an advantage in promoting public health policies if these policies are believed to be correct. Second, inter-agency coordination on public health crisis has been enhanced at both central and local governmental levels since SARS outbreak in 2003, which reduces potential conflict of public health policies. Public health workers should provide policy advocacy to public security authorities and help them change their traditional norms about illicit drug control and obtain their supports for harm reduction. Third, operational research is needed to provide evidence on the benefits of harm reduction programs and convince policy enforcers and lead to revision of unfavorable policy components.
HIV voluntary counseling and testing
HIV voluntary counseling and testing (VCT) is often considered the first step for initiating prevention and/or therapy. One of the strategies for addressing the AIDS epidemic is to give people an opportunity to know their HIV status so that they can take precautions to avoid further spread and receive early therapy if they are infected [53, 54]. However, even in developed countries, many at-risk people do not take VCT. A national British survey in 2000 showed that only one-third of IDUs had VCT in the past 5 years . About one-fourth of the 0.8 to 0.9 million infected people in the United States remain unaware that they are HIV positive . In China, there is a large discrepancy between reported (about 100,000) and estimated (about 1 million) cumulative HIV/AIDS cases thus far. Many at-risk individuals do not seek out standard HIV counseling and testing services. The stigma associated with drug use and HIV/AIDS and fear of arrest or knowing a positive result can be major barriers to access to VCT. A survey among 840 pregnant women and 780 health professionals in Yunnan Province – an epicenter of the HIV/AIDS epidemic in China – found prevalent negative attitudes toward HIV/AIDS. Twenty-three percent of health professionals and 45% of pregnant women thought HIV was a disease of "low class and illegal" people; 48% of health professionals and 59% of pregnant women thought that HIV positive individuals should not be allowed to get married; and 30% of the health professionals were not willing to treat an HIV-positive individual . Cost of traditional VCT, low awareness of risk factors for HIV infection, distance, and inconvenience in time also may prevent access to VCT. Possible solutions include development of outreach programs to offer anonymous testing and counseling to those at heightened risk of HIV infection and adoption of new technologies such as rapid saliva testing and counseling strategies to improve the outreach and efficacy of programs.
Outreach and non-governmental organizations
Non-governmental organizations (NGO) can play a critical role in the delivery of HIV prevention services and other assistance to persons living with AIDS. The flexibility of NGOs enables them to respond quickly to fill in gaps in health care and social services. NGOs can do what government agencies cannot do or are not willing to do – for example, reaching out without perceived threat to IDUs and other marginalized sub-groups whose behaviors are often stigmatized and also put them at higher risk of HIV/AIDS. A recent survey of 29 NGOs in Central and Eastern Europe showed that most NGOs targeted injection drug users; provided needle exchange and HIV prevention peer education; and delivered AIDS presentations and distributed educational materials . In Africa, where the main transmission occurs via heterosexual activity, NGOs are most likely to direct their attention to the general public and to youth; they provide peer-education or community outreach . In both Thailand and Brazil, where success has been observed in controlling the HIV/AIDS epidemic or reducing AIDS mortality, NGO are believed to play a key role, but their programs lack rigorous and systemic evaluation [59, 60]. NGOs often face several difficulties: lack of financial resources [57, 58]; lack of communications with governmental organizations ; governmental indifference or opposition; and AIDS-related stigma .
China has large number of government organized NGOs (GONGOs), including Family Planning Associations, Women's Federation, Red Cross, Youth League, trade unions, and diverse academic associations. The members in these GONGOs have formal positions in governmental organizations while they volunteer at GONGOs. The "true" NGO that has no relationship to the government is just emerging in China. More and more of existing Chinese GONGOs are getting involved in sexually transmitted disease/AIDS prevention. Since the 1990s, the Chinese government has encouraged them to participate in HIV/AIDS control. These government-sponsored NGOs support HIV/AIDS education and academic publications and participate in AIDS research and education with foreign governmental and non-governmental partners, and they can serve as a powerful aid to the Chinese government to achieve the goal of stopping further spread of drug use and HIV/AIDS epidemic.
In spite of its potential for greatly contributing HIV prevention in China, there is little literature in this area. An exception is a recent study (Chen and Liao, 2005) of a Women Federation's HIV prevention program in south China. The study showed that the Women Federation was able to deliver a culturally oriented, multi-level intervention program targeted at female drug users. The data also indicated that the program was successfully in increasing knowledge about HIV/AIDS, increasing condom use, and decreasing needle and syringe sharing among the female drug users in the project. Studies which systematically evaluate the implementation and effectiveness of NGO based intervention programs are greatly needed in the future.