Consequences of Drug Abuse and HIV/AIDS in China: Recommendations for Integrated Care of HIV-Infected Drug Users

Abstract

Drug abuse is a complicated social phenomenon rather than a neural disease. It especially fuels the HIV/AIDS epidemic. Researchers have shown interest in HIV-infected drug users as the socially and medically marginalized population, but they did not provide good enough care. Based on published English and Chinese journal articles and official reports, this integrated literature review summarizes the epidemic of drug abuse and HIV/AIDS, and comments on the clinical and psychosocial consequences, and harm reduction measures in China. Officially registered drug users have reached more than 1 million recently. A little under half of the people living with HIV/AIDS are injection drug users, as they transmit the disease through needle sharing and unprotected sexual behavior. The main consequences of drug abuse and HIV/AIDS included high prevalence of hepatitis viruses and tuberculosis co-infections, severe mental problems and extreme poverty. Even health professionals hold discriminative attitude toward drug users because of condemnation of drug abuse behavior and fear of HIV infection. Although interventions for drug addiction and harm reduction have been scaled up quickly, such as methadone maintenance treatment and needle syringe programs, the measures should be further revised, and the effectiveness needs to be evaluated appropriately. To enhance HIV-infected drug users' quality of life and the utility of medical services, improving health care providers' attitude is the first step. Then securing good quality of integrated medical care services with multidisciplinary cooperation will be essential.

Introduction

D rug abuse and HIV/AIDS are the two global epidemics that are having a particularly adverse effect on the citizens of China. The two epidemics have become intertwined, making both treatment and prevention more complex. In China, injection drug users (IDUs) account for nearly half of the HIV/AIDS patients.^1,2 Since highly active antiretroviral therapy (HAART) became quickly utilized worldwide, HIV/AIDS is no longer necessarily a fatal, quickly debilitating disease, but is rather evolving into a chronic disease. However, HIV-infected drug users derive less benefit than other subpopulations in China.³ With that said, clinical care for the medically and socially marginalized HIV-infected drug users is often challenging and stressful for Chinese clinicians and other health care providers (HCPs) because of the complex array of medical, psychological and social problems related to drug dependency.^4,5 When the needed services are not used, quality of care is jeopardized and patients suffer. How to improve their quality of life and how to control the HIV/AIDS epidemic among IDUs has become a huge Chinese public health concern.

HIV HCPs are in a unique position to help their patients manage their mental and physical disorders with nonjudgmental attitude. So this integrated literature review has two aims: first, to summarize the special clinical and psychological consequences of drug abuse and HIV infection; second, to comment on existing studies, including HCPs' attitudes, psychosocial interventions, and recent harm reduction measures, and point out implications for HIV/AIDS prevention strategies among IDUs in the Chinese cultural context.

Literature Review Methods

A number of sources were used to access data for this integrated review. PubMed and Ovid were searched for articles published between January 2000 and February 2009 using diverse combination of search terms: HIV, AIDS, drug use, drug abuse, drug addict, substance abuse, China, and Chinese. A China National Knowledge Infrastructure (CNKI) search from January 2000 to December 2008 was also undertaken for Chinese articles related to HIV and drug use. The reference lists from relevant review articles and all eligible studies were also searched manually. Other relevant articles and reports released by World Health Organization and the Chinese Ministry of Health were utilized.

All the titles and abstracts in the searched results were scanned, and potentially relevant papers were reviewed by the first author. Studies published in English and Chinese were eligible if they focused on the consequences of drug abuse and HIV/AIDS, and the intervention and care strategies for HIV-infected drug users. Studies with nonspecification of sample origins, except for reviews, and studies presenting repeated data, confusing data, nonrigorous methodology, and probable errors were excluded. As a result, a total of 90 articles were reviewed.

The Prevalence of Drug Abuse and HIV/AIDS in China

After three decades of being drug-free following the creation of the People's Republic of China, thanks to the rigid national antidrug campaign in the 1950s, drug abuse reemerged in the late 1980s along with the Reform and Open-door policy. It spread quickly across the country in the 1990s.^6
–8 The drug abuse problem has spread from Yunnan Province to more than 2000 counties/cities at present, representing more than 70% of the total counties/cities in China. The number of officially registered drug users (according to the police or the voluntary or compulsory drug abuse treatment hospital/clinics' records) increased at a steady rate of 122% per year, from 70,000 in 1990 to 1.14 million by the end of 2004,⁹ and 1.16 million by the end of 2005.^10,11 However, the actual number of drug users is probably much higher than what is officially registered.⁶

Statistics show that heroin is the most abused drug in China (89.34% of total abused drugs in 2003), followed by MDMA (methylenedioxy methamphetamine or ecstasy), for which the rate of use has been growing faster than heroin abuse in recent years in large- and middle-sized cities, and then followed by other opiate substances such as morphine and methadone.^12,13 Most drug abusers are male (>70%), young (<35 years old), unmarried (>60%), and unemployed (>60%), with a low educational level (junior high school education or lower).^12,13 Injection is the main method of delivery for experienced drug users, accounting for 50%–70% of drug use.¹¹

Drug abuse especially fuels the HIV/AIDS epidemic in China. With the first AIDS outbreak observed among injection drug users (IDUs) in Yunnan in 1989, this subgroup has been the main contributor to the HIV/AIDS epidemic.¹⁴ A longitudinal surveillance for HIV-1 incidence in three Chinese cities with prevalent drug abuse showed as high as 9.6% of HIV-1–positive incidences among IDUs (average rate 2.1% with range from 0.57% to 9.6%).¹⁵ Another recent study in southwest China after 3-year follow-up with HIV negative IDUs reported similar rate of 2.3% of HIV incidence.¹⁶ IDUs accounted for a little under half of the people living with HIV/AIDS in recent years,² but it is a predominant transmission route in seven provinces, namely Yunnan, Xinjiang, Guangxi, Guangdong, Guizhou, Sichuan, and Hunan.¹⁷ As of late 2005, there are approximately 288,000 drug users living with HIV/AIDS, accounting for 44.3% of the total number of estimated HIV-positive cases, and among the estimated new HIV cases in each year, 48.6% in 2005 were associated with injection drug use,² and 42% in 2007.¹

Consequences of Drug Abuse and HIV/AIDS: Recommendations for Integrated Health Care

Poor clinical outcomes call for nonjudgmental attitude

The behaviors that put IDUs at risk for HIV also put them at risk for hepatitis. In China, injection drug use is the predominant mode of hepatitis C virus (HCV) infection.¹⁸ Prevalence of HCV infection among IDUs reported varies from 50% to more than 70% in some areas of China,^19
–21 with a systematic review showing 61.4% (95% confidence interval [CI] 55.7%–67.2%).¹⁸ The infection rate of HCV among HIV positive IDUs are even higher, up to 100% in some high HIV prevalence areas.^19,22 The incidence of HCV and hepatitis B (HBV) in a longitudinal study, in which researchers followed 333 HIV-negative IDUs for 3 years, were 33.3 and 11.3 per person-year, respectively.¹⁶ HBV and HCV infections commonly lead to chronic hepatitis with persistent hepatic transaminase abnormities, and ultimately, cirrhosis and hepatocellular carcinoma. Even worse, it often complicates HIV therapeutics among IDUs.

China is a country with a large number of patients with tuberculosis (TB), second only to India in the prevalence of TB in the world.²³ Because of immunodeficiency, HIV-infected individuals are susceptible to TB infection. Thus, TB remains one of the leading opportunistic infections of HIV/AIDS, and accounts for up to 15.9% of the opportunistic infections associated with HIV/AIDS in China with an ever-increasing frequency.²⁴ Among HIV-infected drug users, TB epidemic is extremely prevalent, since drugs, especially heroin, suppresses immunologic functions and makes TB infection easier.²⁵ Drug abuse intertwined with HIV/AIDS and TB infection makes the treatment complicated for each disease. Three of the epidemics may aggravate each other, accelerate disease progression, and increase mortality substantially in patients who are coinfected. For instance, HIV/AIDS and drug abuse alter the onset of TB clinical manifestations, laboratory testing, x-ray characteristics, treatment and prognosis, compared to those for whom TB occurred separately.^24,26

During the literature review, we found that Western literature commonly described studies on skin and soft tissue infections from unsterile intravenous, intramuscular, and subcutaneous injection combined with increased skin carriage of pathogenic organisms resulting to skin ulcers²⁷ but Chinese literature rarely did. To our best knowledge, skin and soft tissue infections among HIV-infected drug users are also common in China, as a recent investigation found that skin and soft tissue infection ranks third in frequency of diseases that heroin abusers develop in China.²⁸ One of the reasons for less literature may be due to the stigmatized attitude that Chinese people, including health workers, hold toward IDUs, and the little experience they have working with them. Most Chinese people consider drug abuse to be a personality flaw/defect or moral weakness rather than a disorder,¹¹ thus they cannot treat drug abusers equally to other patients. In a large survey conducted among 446 doctors who were working with drug users, almost half of them thought that punishment should be an important component of drug abuse treatment, and only half thought drug abuse should be treated as a neural disorder.⁵

Another reason may be that health professionals also hold negative attitudes toward people living with HIV/AIDS (PLWHA). A survey conducted among 780 health professionals in Yunnan found 23% of health professionals thought HIV was a disease of “low class and illegal” people; 48% of health professionals thought that HIV positive individuals should not be allowed to get married; and 30% of the health professionals were unwilling to treat an HIV-positive individual.²⁹

As the very important source of social support and medical care, health care providers play an important role in improving HIV-infected drug users' overall well-being. Changing the stigmatized attitude and enhancing willingness to care for HIV-infected drug users could be the first step for intervention. Sporadic, intensive, interactive professional workshops have shown effective results in improving health providers' attitudes and willingness to care, such as the interventions in south central and west of China.^30,31 The sustainability of this change in attitude was not reported. Such programs need to be maintained and scaled up nationwide, including areas in which HIV and drug abuse are not prevalent.

Psychological problems need to emphasis family support and disentangle dual stigma

Many Chinese studies showed that drug users have negative personality, including low self-esteem and impaired self-cognition, often attributed to their outside behaviors and their low capability to take advantage of social support.^32
–34 The prevalence of depression among drug users was as high as 87.3% in China.³⁵ Literature indicated that drug users expressed higher depression and anxiety rates than in the ordinary population, with little difference between genders by different measurements.^36,37 Drug users usually felt great pressure and conflict about quitting drugs, struggling with the police and drug dealers, suffering the bitterness of the disease, and facing the helpless situation. They experienced a vicious cycle of regret, failure and despair, therefore most of them were not afraid of death; they viewed death as a way out.³⁸ Studies indicated that suicide rate among heroin users was approximately 13 times higher than in the general population.³⁹ However, some argue that accidental drug overdose has also been counted as suicide.⁴⁰

Descriptive studies in China found that drug users had lower self-esteem than the normal population.^41,42 Generally, low self-esteem has been linked to anger, aggression, poor problem-solving skills, impulsiveness, increased substance abuse, more HIV risk-taking behaviors, depression, and suicide.^43
–45 Furthermore, data have indicated that the longer the drug use, the lower the self-esteem.^46
–48 In addition, negative personality was another factor leading to lower self-esteem.⁴⁹

So how about the psychosocial lives of drug abusers who are HIV positive? We acknowledge that HIV/AIDS is a highly stigmatized disease. Because of the stigma and discrimination from the public toward PLWHA, they become greatly depressive, anxious, and feel grief, worthless and guilty.^50,51 Some even experienced psychiatric disorders.⁵² Therefore, when drug abuse and HIV infection bond together, their lives may become even harder due to the dual stigma from both sides. A study implemented in South Central China found that the IDUs reported experiencing higher level of discrimination compared to people who contracted HIV through sex and blood transfusions.⁵⁸ HIV-infected drug users also reported higher perceived stress compared to the MSM and heterosexual transmission groups.⁵³ However, one study being carried out in Yunnan, southwest China, an area with the highest HIV prevalence and most patients infected by sharing needles, indicated that the diagnosis of HIV/AIDS did not exacerbate the stigma already attached to IDUs.³⁸ Chan et al.^54,55 hypothesized (studies based on students' assumptions) that IDUs even experienced a lower level of total stigma after they were diagnosed as HIV positive. It is interesting that if it is true, and more importantly, if IDUs also think they would get more care and less stigma after they get HIV infected, there is a possibility that some of them might not care about HIV infection and thereafter might not change their risk behaviors due to their negative or impaired cognition. However, we do not know the exact situation, especially from the perspective of drug users. HIV-infected drug users' own perceptions of stigma in the Chinese cultural context need to be explored deeply.

Although it is unclear whether the HIV positive diagnosis exacerbates stigma toward IDUs or not, in Chinese culture, shame and blame is usually associated with the way the disease was acquired rather than the disease itself.⁵⁶ Therefore, drug-related behaviors or crimes lead to stigma and discrimination, which creates a vicious cycle of isolation and segregation, marginalization, further drug abuse, which in turn reinforces the stigmatization.³⁸ Drug abuse and HIV also bring stigma and great psychological stress to their families because China is a family-oriented society. The responsibility for family members often makes the whole family stay close and help each other during difficult times. So unlike Western countries, most drug users with HIV in China rely more on their family for support than on other social resources.⁵⁷

Social consequences call for additional financial funds

One of the biggest social problems for HIV-infected drug users is poverty. Most drug users have no stable jobs, living in extreme poverty.⁵⁸ They have less access to get basic goods such as food, housing, and medication.⁵⁷ Previous studies in China showed drug users had a difficult time finding jobs.³⁸ Obviously, getting heroin is the main reason behind poverty for drug abusers. For a person who is on methadone treatment, it costs $1.25 per day, a total of $445 per year, not including the transportation fee. That would no doubt to be an additional burden for no-income drug users.

Aside from drug abuse-related expenditures, medical cost is another burden for HIV-infected people. Although the Chinese government initiated the “Four Frees and One Care” policy in 2003, which stated that it would provide “free antiretroviral (ARV) drugs, free prevention of mother-to-child transmission, free voluntary counseling and testing, free schooling for children orphaned by AIDS, and care to PLWHA,” it does not cover medically necessary components, such as laboratory tests and treatment for opportunistic infections. A major concern for affected villagers was the unaffordable costs of health care.⁵⁹ Médecins Sans Frontières (MSF) carried out an analysis recently on PLWHA's medical cost in China, and discovered that the annual medical cost for those who can get free ARV drugs translated to 116%–340% of an urban resident's annual income and 295%–1200% of the rural resident.⁶⁰ In addition, to be eligible for the “Four Frees and One Care” policy, individual must get drugs from appointed health care sites according to the hukou (an official residency registration card), thus, excluding many migrant workers.

Financial crises bring severe consequences for drug users and PLWHA. Financial matters can lead to high suicide rate among drug users. Klein et al.⁴⁴ found that women who were unemployed or had experienced financial problems in the preceding year were more than twice as likely as those who had jobs or those who has not been facing financial difficulties to think about ending their lives. Homeless individuals as well as those with unstable housing arrangements had inadequate access to health care, poor medical adherence and higher medical costs.⁶¹ In rural areas of China, PLWHA delayed seeking services until symptoms were severe because of the unaffordable health costs.⁵⁹ With HIV/AIDS transforming into a chronic disease and the possibility for PLWHA to live as long as other chronic patients, it is very urgent for Chinese policy-makers to consider additional financial package to sustain the continuity of the HAART treatment, and to also call for long-term international aid, such as the MSF project.

High risk behaviors and HIV/AIDS epidemic call for improvement of harm reduction intervention

The high prevalence of HIV/AIDS among IDUs in China is mainly due to their high-risk behaviors. First of all, sharing needles is the primary mode of HIV transmission. As we know, sharing needles is on a decreasing trend thanks to kinds of prevention and control programs in recent years. For example, according to a survey conducted by the National Institute on Drug Dependence (NIDD) in four areas of Yunnan, Xinjiang, Hubei, and Beijing, 89.2% reported sharing needles in 2001,⁶² the rate was around 50% in 2004,⁶³ and recently was around 30%–40%.^1,64
–66 Although there has been significant improvement, the needle sharing rate is still high.

In addition to needle sharing, unprotected sex is another kind of high-risk behavior for transmitting HIV among drug users. Literature indicated that sex workers who were IDUs were less likely to use condoms than non-IDUs, and female drug users were at greater risk for HIV infection than male drug users.⁶⁷ They were more likely to have multiple sexual partners, and to have an injection drug use sex partner. Many exchange sex for drugs or money—and those who did were also more likely to have unsafe injecting practices.^68,69 It is believed that more than half of female drug users sell sex for drugs.⁷⁰ Male drug users also engage in commercial sex. A survey in Shenzhen and Guangdong detoxification centers observed that 44% of male IDUs had sold sex for drugs or money in the past 6 months.⁶⁹ Furthermore, the rates of using condoms with their mobile or multiple sex companions and stable sex partners were still low (less than 50%).⁶⁹ A recent study in Shanghai showed that the majority (77%) of the IDUs had not used a condom consistently in the previous 3 months, 25.5% had multiple partners, 48.2% had injection drug use partners.²¹

Starting in 2003, China initiated ambitious programs for substance addiction treatment and high-risk behavior reduction, including drug addiction treatment facilities (DATF), traditional Chinese medicine (TCM), methadone maintenance treatment (MMT), needle–syringe programs (NSPs), and other social and educational interventions for prevention of drug abuse.

DATFs in China can be classified approximately into three categories: voluntary DATFs, compulsory DATFs and “re-education through labor” centers.¹¹ Voluntary DATFs are usually supervised by the health departments and relatively well staffed with medical professionals. Compulsory DATFs are run by the public security departments, with drug-dependent individuals usually being admitted and discharged involuntarily. The “re-education through labor” centers belong to the justice system; they are especially for drug-dependent individuals who relapse after compulsory detoxification. However, Liu et al.,⁷¹ in their study of behavioral change of Chinese IDUs who have spent time in DATFs, reported that 95% of IDUs relapsed within 1 year of leaving DATFs, and they also found that the frequency of detoxification treatment was not associated with a decrease in drug practice (injection or sharing needles) and in unprotected sex. This problem was also mentioned in other Chinese articles.^72,73 What is even worse is that, drug users who were in detention were unable to continue HAART, and susceptible to variety of infections due to the poor environmental conditions.⁷⁴ Multidepartmental talks should be held to try to coordinate health issues with the Chinese justice system.

TCM includes herbal medicine, acupuncture, and electroacupuncture, and qigong therapy. However, the biggest concern has been that the effectiveness of the TCM on drug addiction treatment was unclear, with some experts suspecting that the effect was exaggerated.¹¹ TCM may be a potential way to control drug addiction, but the effective results were rarely reported and the evaluation method was unbelievable. The first eight MMT clinics were established between March and June 2004 in China. After a 12-month follow-up of IDUs in the eight MMT clinics, drug injection rate, drug injection frequency, and drug-related crimes had dramatically reduced, and employment rate increased.^75,76 MMT harm reduction program showed effective results in areas with high prevalence of drug abuse, such as in Sichuan and Yunnan Provinces. The needle sharing rate decreased from between 24.7% and 54.1% in the baseline years (2002 or 2003) to between 11% and 18.9% in 2004.⁷⁷ Then MMT clinics were scaled up quickly. By October 2007, 397 clinics in 22 provinces certified to provide MMT were established across the country.¹ According to the Five-Year Action Plan to Control HIV/AIDS (2006–2010), there were over 500 officially recorded MMT clinics available for 40% of heroin abusers by the end of 2007, and by 2010 coverage should increase to 70% of heroin users. Although the MMT programs have shown promise in China, the programs face a rather high rate (30%–40%) of dropout,⁷⁸ mainly due to the relapse of drug use in patients and the following forced detoxification.⁷⁹ Another reason for disruption of MMT is that local police may arrest drug users when they are attending MMT programs. In China, one of the requirements to get MMT is that they must be local residents and have stable housing according to government guideline.⁸⁰ Thus, it denies migrant IDUs of the service, especially female IDUs who engage in commercial sex work and who migrate to various places to conduct their business.⁶⁸hird problem is that behavioral interventions are not commonly used in China's MMT, and motivational enhancement therapy and motivational interviewing could increase MMT's effectiveness. For instance, self-help groups like Narcotics Anonymous (NA) in Yunnan MMT showed sustainable success.⁸¹ In conclusion, increasing behavioral intervention and quality of psychosocial care within MMT is necessary to expand these harm-reduction programs throughout China.

Needle syringe programs were initiated in 2000 in China. By the end of 2005, there were 92 NSPs sites in 12 provinces, among which over two thirds (70.7%) were located in southwestern and northwestern provinces, where the HIV epidemic among drugs users is most severe. Forty-four (47.8%) were funded by the national government and 40 (43.5%) by international funding. The remainder was funded jointly by both domestic and international funds.⁸² The program was substantially scaled up in 2006, from 93 sites to 729 by the year's end.¹⁰ According the Five-Year Action Plan to Control HIV/AIDS (2006–2010), by the end of 2007, NSPs served at least 30% of officially registered IDUs, and by 2010 coverage should increase to 50% of IDUs. NSPs showed effectiveness in decreasing needle sharing rate and HIV infection rate. For instance, the needle sharing rate dropped from 76.8% to 35.3% in an intervention study after a 12-month follow-up.⁸³ Another recent large-scale distribution of sterile injection equipment and peer educator outreach intervention project in China and Vietnam showed significant decline of HIV incidence among new IDUs, and there was no indication that the project led to any increase in IDUs.⁸⁴ However, under Chinese culture, NSPs are regarded more as condoning and even encouraging drug use and do not have as many benefits for society as a whole.⁷⁶ This perspective is even shared among the police departments.⁸² For injection drug users, only 7.3% were using the services in a large study in China.⁸² The main reasons included that they did not know where or with whom they could exchange needles and that they were scared of being arrested. Changing the attitude toward NSP among the public, especially the police department, is the key point of NSP success, although such education programs are rarely carried out in China.

Social and educational interventions include: distribution of information and education, including safe sex education and condom distribution; voluntary counseling and testing for HIV, and outreach and peer education; those were reported as having positive effects on reducing high risk behaviors.^77,85
–87

Providing free voluntary counseling and testing (VCT) is considered as the first step to fight the HIV/AIDS epidemic in China. However, it is common that many at-risk people do not use VCT services. There is still a big discrepancy between the reported (223,501) and estimated (700,000) accumulative HIV/AIDS cases in China so far.¹ Some programs were designed to promote the utilization of VCT. The China-U.K. project in Sichuan Province trained medical and health workers as outreach workers, who provide information about HIV prevention, including HIV/STD-related knowledge, needle cleaning techniques, and condom promotion. Through these outreach services, IDUs were also invited to use free VCT services, which were conducted by trained professionals at clinics of the local Center for Disease Control and Prevention (CDC) and other centers. Peer educators were trained to provide clean syringes and condoms as well as the related information.⁷⁷

Some pilot intervention programs have been carried out by semi-non-governmental organizations (NGO; funded by government) in China. Because they are organized by grass-root groups, so they have an easier way in reaching high-risk populations such as injection drug users, sex workers, and MSM. In 2002 a women's federation organization in Guangxi Province piloted a study, which increased female drug users' knowledge about HIV/AIDS, increased condom use, and decreased needle sharing.⁸⁶ A community-based prevention intervention including different levels of community members also proved efficient in decreasing drug use, increasing HIV/AIDS knowledge, and improving attitude toward drug users.⁸⁸ But the sustainability has not been tested. The China-USA Daytop Village for drug abusers, created in 1997 in Yunnan, has shown positive results. It adopted the community therapy model—the cognitive and spirit intervention—as a major means to conduct detoxification, rehabilitation and harm reduction.⁸⁹ However, very little quantitative data showing how effective their methods are has been reported in e literature. Such interventions need to be retested and scaled up urgently in provinces with high drug abuse prevalence, and incorporate the research results.

Health care providers are in a unique position to identify and reduce their HIV-infected drug users' transmission-related behaviors. However, providing information, counseling, and other support to help their patients change those behaviors sometimes may jeopardize the relationship and trust between health care providers and HIV-infected drug users.⁹⁰ As we discussed above, harm reduction strategies and interventions are much more than improving the well-being of HIV-infected drug users in China. These drug users are generally considered the source of HIV transmission, and may be condemned by health care providers because of their high risk behavior. That would be one of the reasons why so many drug users have not utilized voluntary counseling and testing (VCT). But there is lack of such literature about how health professionals should provide such counseling in China, although some might have already applied such strategies. The discussion with HIV-infected drug users does not have to focus on the patients' potential of transmitting HIV to others, and instead should address that unsafe behavior, such as needling sharing and unsafe sex, may potentially exacerbate their own poor health.⁹⁰

Summary of Implications for HIV-Infected Drug Users

From what has been discussed above, we can note that researchers are interested in HIV-infected drug users, but these drug users have not been taken care of enough. In order to enhance their quality of life and the utility of medical services, improving health care providers' attitude is the first step, and then providing good quality of integrated medical care services will be essential. Although there are many research articles focusing on HIV/AIDS and drug users, more research is needed to address the limitations of existing studies, such as the harm reduction study in China, and there is more need to design multidiscplinary psychosocial interventions to improve HIV-infected drug users' mental health and overall well-being. Another disappointing fact is that there are many Chinese investigations and intervention studies, but seldom were they reported with rigorous methodology. Chinese researchers and clinical workers have the capacity to carry out culturally, socially, and historically appropriate intervention programs. Thus, it is very important for them to not only implement the program seriously, but also report it rigorously.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

References

Ministry of Health of China, UNAIDS, and WHO. 2007 Update on the HIV/AIDS Epidemic and Rresponse in China. Beijing: Ministry of Health, 2007.

Ministry of Health of China, UNAIDS, and WHO. 2005 Update on the HIV/AIDS epidemic and response in China. Beijing: Ministry of Health, 2005.

Wang

, He

, Li

et al. Self-Reported adherence to antiretroviral treatment among HIV-infected people in Central China. AIDS Patient Care STDs, 2008; 22:71–80.

Kulsudjarit

. Drug problem in southeast and southwest Asia. Ann NY Acad Sci, 2004; 1025:446–457.

Tang

, Wiste

, Mao

, Hou

. Attitudes, knowledge, and perceptions of Chinese doctors toward drug abuse. J Subst Abuse Treat, 2005; 29:215–220.

Fang

, Wang

, Shi

, Liu

, Lu

. Recent trends in drug abuse in China. Acta Pharmacol Sin, 2006; 27:140–144.

Chen

, Huang

. Drug problems in China: Recent trends, countermeasures, and challenges. Int J Offender Ther Comp Criminol, 2007; 51:98–109.

Qian

, Schumacher

, Chen

, Ruan

. Injection drug use and HIV/AIDS in China: Review of current situation, prevention and policy implications. Harm Reduct J, 2006; 3:4.

, Fang

, Wang

. Drug abuse in China: Past, present and future. Cell Mol Neurobiol, 2008; 4:479–569.

10.

, Sullivan

, Wang

, Rotheram-Borus

, Detels

. Evolution of China's response to HIV/AIDS. Lancet, 2007; 369:679–690.

11.

Tang

, Hao

. Improving drug addiction treatment in China. Addiction, 2007; 102:1057–1063.

12.

National Institute on Drug Dependence and Drug Abuse Surveillance Center. Report of drug surveillance 2003. Beijing: NDASC NIDD, 2003.

13.

National Institute on Drug Dependence and National Drug Abuse Surveillance Center. Report of drug surveillance 2004. Beijing: NDASC, NIDD, 2004.

14.

Qian

, Vermund

, Wang

. Risk of HIV/AIDS in China: Subpopulations of special importance. Sex Transm Infect, 2005; 81:442–447.

15.

Jiang

, Wang

, Ni

et al. HIV-1 incidence estimates using IgG-capture BED-enzyme immunoassay from surveillance sites of injection drug users in three cities of China. AIDS, 2007; 21:S47–S51.

16.

Ruan

, Qin

, Yin

et al. Incidence of HIV, hepatitis C and hepatitis B viruses among injection drug users in southwestern China: A 3-year follow-up study. AIDS, 2007; 21:S39–S46.

17.

, Wang

, Wu

et al. Estimating the number of people at risk for and living with HIV in China in 2005: Methods and results. Sex Transm Infect, 2006; 82,Suppl 3:87–91iii.

18.

Xia

, Luo

, Bai

, Yu

. Epidemiology of hepatitis C virus infection among injection drug users in China: Systematic review and meta-analysis. Public Health, 2008; 122:990–1003.

19.

Ruan

, Hong

, Liu

et al. Community-based survey of HCV and HIV coinfection in injection drug abusers in Sichuan Province of China. World J Gastroenterol, 2004; 10:1589–1593.

20.

Garten

, Zhang

, Lai

, Liu

, Chen

, Yu

. Coinfection with HIV and hepatitis C virus among injection drug users in southern China. Clin Infect Dis, 2005; 41,Suppl 1:S18–24.

21.

Zhao

, Du

, Lu

et al. HIV sexual risk behaviors among injection drug users in Shanghai. Drug Alcohol Depend, 2006; 82,Suppl 1:S43–47.

22.

Lai

, Liu

, Chen

et al. Changes in HIV-1 incidence in heroin users in Guangxi Province, China. J Acquir Immune Defic Syndr, 2001; 26:365–370.

23.

Jiang

, Lu

, Zhang

et al. A cross-sectional study of HIV and tuberculosis coinfection cases in mainland China. South Med J, 2008; 101:914–917.

24.

. Review on coinfection of HIV/AIDS and tuberculosis [in Chinese] Int Med China, 2007; 2:604–606.

25.

Wang

, Xiao

, Lu

. Case-control retrospective study of pulmonary tuberculosis in heroin-abusing patients in China. J Psychoactive Drugs, 2006; 38:203–205.

26.

Huang

, He

, Yang

. Tuberculosis and HIV/AIDS [in Chinese] Henan J Prev Med, 2008; 19:224–226.

27.

Bruce

, Altice

. Clinical care of the HIV-infected drug user. Infect Dis Clin North Am, 2007; 21:149–179.

28.

Chen

, Wang

, Ruan

. A succesional analysis of spectrum of disease on the cases of heroin dependence with physical disease in the past decade [in Chinese] Chin J Drug Abuse Prev Treat, 2008; 14:22–25.

29.

Hesketh

, Duo

, Li

, Tomkins

. Attitudes to HIV and HIV testing in high prevalence areas of China. Informing the introduction of voluntary counselling and testing programmes Sex Trans Infect, 2005; 81:108–112.

30.

Williams

, Wang

, Burgess

, Wu

, Gong

, Li

. Effectiveness of an HIV/AIDS educational programme for Chinese nurses. J Adv Nurs, 2006; 53:710–720.

31.

, Li

, Wu

et al. A brief HIV stigma reduction intervention for service providers in China. AIDS Patient Care STDs, 2008; 22:513–520.

32.

Liu

. Personality characteristics and psychological correction of addicts under treatment. Chin J Clin Rehab, 2006; 10:52–54.

33.

Luo

, Jin

, Li

, Mo

. Drug users' locus of control and their correlative analysis. Chin J Drug Abuse Prev Treat, 2006; 3:2–4.

34.

Xue

. Study of mental pattern and utilization of social support of drug addicts. Chin J Health Psychol, 2007; 15:833–835.

35.

Zhang

, Li

. A clinical controlled study of Trazadone and Amitriptyline in the treatment of anxiety and depression of heroin addicts. Chin J Drug Depend, 2003; 12:201–203.

36.

, Lin

, Wang

. Drug addicts' mental health conditions and their relations with relapse reasons. Chin J Clin Psychol, 2006; 1:18–20.

37.

Han

, Han

. Mental health and its related factors of heroin addicts. Chin J Drug Depend, 2006; 2:14–16.

38.

Deng

, Li

, Sringernyuang

, Zhang

. Drug abuse, HIV/AIDS and stigmatisation in a Dai community in Yunnan, China. Soc Sci Med, 2007; 64:1560–1571.

39.

Wilcox

, Conner

, Caine

. Association of alcohol and drug use disorders and completed suicide: An empirical review of cohort studies. Drug Alcohol Depend, 2004; 76,Suppl:S11–19.

40.

Bradvik

, Frank

, Hulenvik

, Medvedeo

, Berglund

. Heroin addicts reporting previous heroin overdoses also report suicide attempts. Suicide Life Threat Behav, 2007; 37:475–481.

41.

Ren

, Zhao

. A comparative study on self-esteem between drug addicts and normal people. Chin J Health Psychol, 2002; 5:27–29.

42.

Yang

, Fan

. A correlation study of self-esteem and coping style on 268 male drug addicts. Chin J Clin Psychol, 2006; 2:21–23.

43.

Elifson

, Klein

, Sterk

. Drug problems and “at risk” women's involvement in HIV risk behaviors. Soz Praventivmed, 2004; 49:198–207.

44.

Klein

, Elifson

, Sterk

. Predictors of suicidal ideation among “at risk” cocaine-using African American women. Suicide Life Threat Behav, 2006; 36:336–348.

45.

Elifson

, Klein

, Sterk

. Predictors of sexual risk-taking among new drug users. J Sex Res, 2006; 43:318–327.

46.

Yang

, Kang

. The investigation and analysis of interpersonal relationship and self-esteem on 242 cases of female. Drug Psychology Exploration, 2004; 2:14–16.

47.

Yang

, Liu

, Kang

. The investigation and analysis of self-esteem and background on 242 cases of women drug users. Stud Psychol Behav, 2004; 2:7–9.

48.

. The related research about the relationship among the level of self-esteem,the coping style and the drug addictive behavior of drug users. Chin J Soc Med, 2006; 4:13–15.

49.

Yang

, Zhao

, Chen

. The research on the relation of addicting-behaviors, personality, social support and self-esteem on the male drug addicts. Psychol Dev Educ, 2004; 3:8–10.

50.

Lee

, Kochman

, Sikkema

. Internalized stigma among people living with HIV-AIDS. AIDS Behav, 2002; 6:309–319.

51.

Duffy

. Suffering, shame, and silence: The stigma of HIV/AIDS. J Assoc Nurses AIDS Care, 2005; 16:13–20.

52.

Tang

. Analyses on mental state of accompanying relatives with psychogenia inpatients of HIV infection. Chin J Health Psychol, 2007; 15:825–826.

53.

, Lau

, Mak

et al. Development of the perceived stress scale for people living with HIV/AIDS in China. AIDS Patient Care STDs, 2008; 22:989–998.

54.

Chan

, Stoove

, Sringernyuang

, Reidpath

. Stigmatization of AIDS patients: Disentangling Thai nursing students' attitudes towards HIV/AIDS, drug use, and commercial sex. AIDS Behav, 2008; 12:146–157.

55.

Chan

, Yang

, Zhang

, Reidpath

. Disentangling the stigma of HIV/AIDS from the stigmas of drugs use, commercial sex and commercial blood donation—A factorial survey of medical students in China. BMC Public Health, 2007; 7:280.

56.

Cao

, Sullivan

, Xu

, Wu

. Understanding HIV-related stigma and discrimination in a “blameless” population. AIDS Educ Prev, 2006; 18:518–528.

57.

, Wu

, Sun

, Cui

, Jia

. Understanding family support for people living with HIV/AIDS in Yunnan, China. AIDS Behav, 2006; 10:509–517.

58.

, Ge

, Zhang

, Wen

. [Survey of behaviors and knowledge about HIV/AIDS among intravenous drug users at a city in Sichuan Province] Sichuan Da Xue Xue Bao Yi Xue Ban, 2004; 35:376–378.

59.

, Sullivan

, Dou

, Wu

. Economic stress and HIV-associated health care utilization in a rural region of China: A qualitative study. AIDS Patient Care STDs, 2007; 21:787–798.

60.

Moon

, Van Leemput

, Durier

et al.

Out-of-pocket costs of AIDS care in China: are free antiretroviral drugs enough?

AIDS Care, 2008; 20:984–994.

61.

Uphold

, Mkanta

. Review: Use of health care services among persons living with HIV infection: State of the science and future directions. AIDS Patient Care STDs, 2005; 19:473–485.

62.

Liu

, Lian

, Mu

, Zhou

, Wang

, Gu

. Knowledge and risk behavior on HIV/AIDS among drug users in four areas in China. Chin J Drug Depend, 2001; 1:21–24.

63.

Xiao

, Jie

, Zhang

, Wen

. Survey of behaviors and knowledge about HIV/AIDS among intravenous drug users at a city in Sichuan Province. J Sichuan Univ (Med Sci Edi), 2004; 376–378.

64.

Wang

, Chen

, Maiwulani

et al. Analysis on HIV associated risk behavior with influencing factors among injection drug user. Chin J Public Health, 2007; 23:1025–1026.

65.

, Wang

, Lai

, Xia

, Zhou

, Liang

. Investigation of the AIDS-related behaviors among the injection drug users in 2005 in Zhongshan. Occup Health, 2007; 23:1624–1625.

66.

Yang

, Latkin

, Celentano

, Luo

. Prevalence and correlates of HIV risk behaviors among drug users in China. AIDS Behav, 2006; 10:71–81.

67.

Lau

, Zhang

et al. Comparing prevalence of condom use among 15,379 female sex workers injecting or not injecting drugs in China. Sex Transm Dis, 2007; 34:908–916.

68.

Choi

, Cheung

, Chen

. Gender and HIV risk behavior among intravenous drug users in Sichuan Province, China. Soc Sci Med, 2006; 62:1672–1684.

69.

Lau

, Feng

, Lin

, Wang

, Tsui

. Needle sharing and sex-related risk behaviours among drug users in Shenzhen, a city in Guangdong, southern China. AIDS Care, 2005; 17:166–181.

70.

Yang

, Liu

. Textbook of Drug Prevention and Drug Control. Beijing: People's Publishing House, 2005; 7–8.

71.

Liu

, Grusky

, Zhu

, Li

. Do drug users in China who frequently receive detoxification treatment change their risky drug use practices and sexual behavior? Drug Alcohol Depend, 2006; 84:114–121.

72.

Wang

. HIV/AIDS Epidemic and Control in China [in Chinese] Beijing: Beijing Publisher, 2006; 164–184.

73.

. A survey of relapse among 120 ex-addicts discharged from reeducation-through-labor centers. Chin J Drug Depend, 1999; 42–43.

74.

Cohen

, Amon

. Health and human rights concerns of drug users in detention in Guangxi Province, China. PLoS Med, 2008; 5:e234.

75.

Pang

, Hao

, Mi

et al. Effectiveness of first eight methadone maintenance treatment clinics in China. AIDS, 2007; 21:S103–S107.

76.

Sullivan

, Wu

. Rapid scale up of harm reduction in China. Int J Drug Policy, 2007; 18:118–128.

77.

Lau

, Zhang

et al. Changes in the prevalence of HIV-related behaviors and perceptions among 1832 injecting drug users in Sichuan, China. Sex Transm Dis, 2008; 35:325–335.

78.

, Fang

, Wang

. Drug abuse in China: Past, present and future. Cell Mol Neurobiol, 2008; 28:479–490.

79.

Zhang

, Shan

, Trizzino

et al. HIV incidence, retention rate, and baseline predictors of HIV incidence and retention in a prospective cohort study of injection drug users in Xinjiang, China. Int J Infect Dis, 2007; 11:318–323.

80.

Ministry of Health, Ministry of Public Security, and State Drug Administration. Guidelines of Pilot Studies of Community Drug Maintenance Treatment for Heroin Addicts. Beijng: Ministry of Health, Ministry of Public Security and State Drug Administration, 2003.

81.

Michels

, Fang

, Zhao

, Lu

. Comparison of drug abuse in Germany and China. Acta Pharmacol Sin, 2007; 28:1505–1518.

82.

Liu

, Sullivan

, Wu

. An evaluation of needle exchange programmes in China. AIDS, 2007; 21:S123–S128.

83.

, Luo

, Sullivan

et al. Evaluation of a needle social marketing strategy to control HIV among injecting drug users in China. AIDS, 2007; 21:S115–S122.

84.

Des Jarlais

, Kling

, Hammett

et al. Reducing HIV infection among new injecting drug users in the China-Vietnam Cross Border Project. AIDS, 2007; 21,Suppl 8:S109–114.

85.

, Zhang

, Li

. Efficiency of congnitive behavior therapy on the negative emotions of drug addicts. Chin J Nurs, 2006; 41:994–995.

86.

Chen

, Liao

. A pilot study of the NGO-based relational intervention model for HIV prevention among drug users in China. AIDS Educ Prev, 2005; 17:503–514.

87.

Zhao

, Wang

, Lu

, Xu

, McCoy

. Risk behaviors and HIV/AIDS prevention education among IDUs in drug treatment in Shanghai. J Urban Health, 2005; 82:84–91.

88.

, Detels

, Zhang

, Li

. Community-based trial to prevent drug use among youths in Yunnan, China. Am J Public Health, 2002; 92:1952–1957.

89.

Yang

, Feng

, GB

. Rehabilitation model of China-U.S.A. Daytop Village on drug detoxification. Soft Sci Health, 2002; 16:23–26.

90.

Gerbert

, Danley

, Herzig

et al. Reframing “prevention with positives”: Incorporating counseling techniques that improve the health of HIV-positive patients. AIDS Patient Care STDs, 2006; 20:19–29.