Scaling up the national methadone maintenance treatment program in China: achievements and challenges

The Update of HIV-1 Prevalence and Incidence and Spatio-Temporal Analyses of HIV Recent Infection Among Four Sub-Groups in Sichuan, China During Surveillance Period Between 2016 and 2022

Background

Sichuan Province has gradually become a hot-spot for HIV/AIDS. Little is known about the HIV-1 incidence and prevalence among four sub-groups since 2015. Meanwhile, the distributions of hot-spot areas related to recent infection cases that indicate current transmission among the four subgroups are also rare.

Objective

The main purpose of this study was to assess the HIV-1 prevalence and incidence and to visualize the distributions of hot-spot areas of current transmission among four subgroups (people who inject drugs, male STD clinic attendees, female sex workers and men who had sex with men) during the surveillance period in Sichuan province between 2016 and 2022.

Results

Of the 267,617 individuals, 2158 HIV-positive samples were tested with Lag-Avidity EIA, among which 493 samples were identified as recent infections. Among people who inject drugs (PWID), both HIV-1 prevalence (from 1.41% to 0.34%) and incidence (from 0.03% to 0.140%) showed a significant decreasing trend. Among men who had sex with men (MSM), female sex workers (FSWs), and male STD clinic attendees, HIV-1 prevalence indicated significant decreasing trends, whereas HIV-1 incidence showed no significant changes. Spatial analysis demonstrated the formation of hot-spots and clusters of current transmissions sharing regional differences, mainly concentrated in the southeast, and most of these were consecutive hot-spots.

Conclusion

The prevention and control were efficacious and persistent. However, among the other three subgroups, there is a need for a regional cooperative in prevention and control approaches and collaborative research in many aspects.

HIV-1 CRF07_BC transmission dynamics in China: two decades of national molecular surveillance

By analyzing an unprecedentedly large, longitudinal HIV-1 CRF07_BC sequence dataset collected from China in the past two decades, we sought to build CRF07_BC lengthwise transmission networks, and understand its transmission dynamics. We divided CRF07_BC into two clusters based on phylogenetic analysis and an estimation of the pairwise genetic distance at 0.7%. Of 6213 sequences, 3607 (58.1%) linked to ≥1 other sequence. CRF07_BC was divided into two clusters: 07BC_O and 07BC_N. The 07BC_O is the original CRF07_BC, circulating in people who inject drugs (PWID) and heterosexuals, predominantly in southwestern and northwestern provinces of China. The 07BC_N is a new cluster, identified mostly in men having sex with men (MSM) in the northern provinces of China. Bayesian analysis indicates that CRF07_BC has experienced two phases of exponential growth, which was first driven by 07BC_O then 07BC_N. Compared to 07BC_O, the proportion of the parameter of population transmission risk (TR) of 07BC_N has risen constantly. The power-law function analyses reveal that 07BC_N has increased over years with higher degree. In 07BC_N, only 13.16% of MSM were linked to other risk groups, but these links represent 41.45%, 54.25%, and 55.07% of links among heterosexual females, heterosexual males, and male PWID respectively. This study indicates that CRF07_BC has evolved into two clusters in China, and their distributions are distinct across risk groups and geographical regions. 07BC_N shows a greater risk of transmission, and has gradually replaced 07BC_O. Furthermore, the results show that strengthening the MSM interventions could lower the rapidity of 07BC_N transmission in all risk groups.

The Abuse Characteristics of Amphetamine-Type Stimulants in Patients Receiving Methadone Maintenance Treatment and Buprenorphine Maintenance Treatment

Objective

The purpose of this study was to retrospectively investigate the abuse characteristics of amphetamine-type stimulants (ATS) in patients receiving methadone maintenance treatment (MMT) and buprenorphine maintenance treatment (BMT).

Methods

A total of 58 MMT and 51 BMT patients abusing ATS were recruited from the drug maintenance treatment clinic of Ningbo Addiction Research and Treatment Center from January 2018 to December 2019. They were assessed using the amphetamine abuse questionnaire (AAQ), addiction severity index (ASI) and Barratt impulsiveness scale (BIS). Moreover, 40 MMT control patients, 40 BMT control patients and 20 healthy controls were also assessed using the BIS. All information was collected using the amphetamine abuse questionnaire (AAQ), Chinese version of addiction severity index (ASI-C) and Chinese version of Barratt impulsiveness scale (BIS-C) conducted by qualified psychologists.

Results

The interval of amphetamine use in the MMT group was shorter than the BMT group (P < 0.05). The drug use subscale score of ASI was higher in the MMT group than the BMT group (P < 0.05). The respective and total scores of attentional impulsiveness, motor impulsiveness and non-planning impulsiveness in BIS in the MMT group were all higher than the MMT control group (P < 0.05). The scores of motor impulsiveness and non-planning impulsiveness in the BMT group were higher than the BMT control group (P < 0.05). The respective and total scores in BIS in the MMT control group and the BMT control group were all higher than those in the healthy controls.

Conclusion

The patients showing amphetamine abuse in maintenance therapy had a greater impulsiveness than those having other simple maintenance treatments, and patients under MMT may be more addicted to amphetamines in comparison with those having BMT.

Job Satisfaction Among Methadone Maintenance Treatment Clinic Service Providers in Jiangsu, China: A Cross-sectional Survey

OBJECTIVE

Service providers' job satisfaction is critical to the stability of the work force and thereby the effectiveness of methadone maintenance treatment (MMT) programs. This study aimed to explore MMT clinic service providers' job satisfaction and associated factors in Jiangsu, China.

METHODS

This secondary study used baseline data of a randomized interventional trial implemented in Jiangsu, China. A survey was conducted among 76 MMT service providers using the computer-assisted self-interview (CASI) method. Job satisfaction responses were assessed via a 30-item scale, with a higher score indicating a higher level of job satisfaction. Perceived institutional support and perceived stigma due to working with drug users were measured using a 9-item scale. Correlation and multiple linear regression analyses were performed to identify factors associated with job satisfaction.

RESULTS

Correlation analyses found a significant association between job satisfaction and having professional experience in the prevention and control of HIV, other sexually transmitted infections, or other infectious diseases (P = 0.046). Multiple regression analyses revealed that working at MMT clinics affiliated with Center for Disease Control and Prevention sites was associated with a lower level of job satisfaction (P = 0.014), and perception of greater institutional support (P = 0.001) was associated with a higher level of job satisfaction.

CONCLUSION

Job satisfaction among MMT clinic service providers was moderate in our study. Our findings suggest that institutional support for providers should be improved, and that acquisition of additional expertise should be encouraged.

Economic and epidemiological evaluation of interventions to reduce the burden of hepatitis C in Yunnan province, China

BACKGROUND

The paradigm shift in hepatitis C virus (HCV) treatment options in the last five years has raised the prospect of eliminating the disease as a global health threat. This will require a step-change in the number being treated with the new direct-acting antivirals (DAAs). Given constrained budgets and competing priorities, policy makers need information on how to scale-up access to HCV treatment. To inform such decisions, we examined the cost effectiveness of screening and treatment interventions in Yunnan, China.

METHODS AND FINDINGS

We simulated the HCV epidemic using a previously published model of HCV transmission and disease progression, calibrated to Yunnan data, and implemented a range of treatment and screening interventions from 2019. We incorporated treatment, diagnosis, and medical costs (expressed in 2019 US Dollars, USD) to estimate the lifetime benefits and costs of interventions. Using this model, we asked: is introducing DAAs cost effective from a healthcare sector perspective; what is the optimal combination of screening interventions; and what is the societal return on investment of intervention? The incremental cost-effectiveness ratio (ICER) of switching to DAAs with a median cost of 7,400 USD (50,000 Chinese Yuan) per course is 500 USD/disability adjusted life year (DALY) averted; at a threshold of 50% of Yunnan gross domestic product (2,600 USD), switching to DAAs is cost effective 94% of the time. At this threshold, the optimal, cost-effective intervention comprises screening people who inject drugs, those in HIV care, men who have sex with men, and ensuring access to DAAs for all those newly diagnosed with HCV. For each USD invested in this intervention, there is an additional 0·80 USD (95% credible interval: 0·17-1·91) returned through reduced costs of disease or increased productivity. Returns on investment are lower (and potentially negative) if a sufficiently long-term horizon, encompassing the full stream of future benefits, is not adopted. The study had two key limitations: costing data were not always specific to Yunnan province but were taken from China-level studies; and modelled interventions may require more operational research to ensure they can be effectively and efficiently rolled-out to the entire province.

CONCLUSIONS

Introducing DAAs is cost effective, the optimal package of screening measures is focussed on higher risk groups, and there are likely to be positive returns from investing in such HCV interventions. Our analysis shows that targeted investment in HCV interventions will have net benefits to society; these benefits will only increase as DAA costs fall.

Changes in quality of life and its associated factors among illicit drug users in Vietnamese mountainous provinces: a 12-month follow-up study

Background

Sustainability of methadone maintenance treatment (MMT) program involves regularly assessing its impact on health and social outcomes of drug users in different settings, particularly in disadvantaged areas. In this study, we evaluated the change in quality of life (QoL), and identified associated factors amongst drug users over the course of 12-month MMT in Vietnamese mountainous provinces.

Methods

We conducted a longitudinal study among patients from 6 MMT clinics in three mountainous provinces of Vietnam. At baseline, we screened 300 participants and after a 12-month treatment, 244 participants remained to involve in the study. World Health Organization Quality of Life short form instrument (WHOQOL-BREF) was used to measure the QoL of patients. The magnitude of the changes was extrapolated.

Results

There were significant changes in all four dimensions of quality of life measured by WHOQoL-BREF between baseline and 12 months with the effect size ranged from 0.21 to 0.24. Increased age, being workers compared to unemployment and having health problems or comorbidities were positively related to reduced scores of QoL.

Conclusions

To conclude, we observed a significant increase in the QoL level regarding physical, psychological, social relationships and environmental aspects among people who used drug after 12 months of MMT. Findings from this study emphasize the role of continuously receiving MMT treatment among people using drugs to enhance their QoL.

HIV Epidemiology and Prevention in Southwestern China: Trends from 1996-2017

The aim of this review is to describe long-term HIV epidemiology and prevention trends in Guangxi, a provincial-level region located along a major drug trafficking corridor in southwestern China. Between 1996 and 2006, HIV transmission in Guangxi was primarily fueled by Injection Drug Use (IDU). Since 2006, heterosexual sex has become the dominant mode of HIV transmission, followed by drug injection. Moreover, older, heterosexual adults appear to be at increased risk for HIV. The vast majority of new HIV cases are attributed to local HIV subtypes already circulating within Guangxi (93%), though imported subtypes are associated with younger age groups. Since 2011, HIV incidence in Guangxi has stabilized, due in part to HIV prevention efforts that include expanded HIV testing, antiretroviral treatment, and other intervention measures. Between 1996 and 2017, Guangxi, China experienced dramatic changes in the primary HIV transmission mode and at-risk age group. Due in part to local and National AIDS control and prevention campaigns, HIV incidence trends in Guangxi no longer appear to be increasing.

The Association between Living Status Transitions, Behavior Changes and Family Relationship Improvement among Methadone Maintenance Treatment Participants in Guangdong, China

The quality of family relationships is important for individual and family well-being. Improving family relationships is also an important goal in methadone maintenance treatment (MMT). Little is known about factors associated with the improvement of family relationships among MMT clients. This study aimed to identify factors associated with family relationship improvement in MMT. We retrospectively analyzed existing data from 2006 to 2014 at 15 MMT clinics in Guangdong, China, including 2171 subjects with 4691 follow-ups. Generalized estimating equations were used to investigate the association between living status transitions, behavior changes and family relationship improvement, with covariates controlled for. Family relationship improvement was found in 23.1% of all follow-up intervals. Participants who began living with family, living on a regular wage, and gained employment were more likely to have improved family relationships. The quality of family relationships also improved among participants who ceased contact with drug-addicted fellows, ceased drug use, and those who were sexually active. These results suggest that improvement in living status, positive changes in drug use, and sexual activity are associated with family relationship improvement and corresponding interventions may be developed to facilitate clients’ recovery.

Hepatitis C Virus Treatment Status and Barriers among Patients in Methadone Maintenance Treatment Clinics in Guangdong Province, China: A Cross-Sectional, Observational Study

We aimed to evaluate the status and barriers related to hepatitis C virus (HCV) treatment among Chinese methadone maintenance treatment (MMT) clients, and the willingness and barriers of patients to accept directly observed treatment (DOT) service and oral direct-acting antivirals (DAAs). We conducted a cross-sectional survey from July to October 2017 in Guangdong Province, China, involving 678 HCV antibody-positive MMT patients. If they reported being infected with HCV, then their HCV treatment experience, willingness to use DOT and DAAs, along with any barriers, were collected. Logistic regression analysis was used to identify the correlates of initiating HCV treatment. Among those reporting HCV infection (54%, 366/678), 39% (144/366) initiated treatment; however, 38% (55/144) interrupted and 55% (79/135) delayed treatment for 15 months. Seventy-five percent (273/366) and 53% (195/366) were willing to use DOT and DAAs, respectively. Unaffordable medical costs and insignificant symptoms were the major barriers to HCV treatment and accepting DOT or DAAs. The lack of a stable residence, being a woman, and having ever injected drugs were all associated with a low probability of initiating treatment (p < 0.05). This study highlights a limited uptake of HCV treatment among MMT patients, and a need to strengthen the popularity of DOT and DAAs and integrate them into Chinese MMT clinics.

The Decade-Long Chinese Methadone Maintenance Therapy Yields Large Population and Economic Benefits for Drug Users in Reducing Harm, HIV and HCV Disease Burden

Objectives: We aimed to conduct a comprehensive evaluation of the population impact of methadone maintenance treatment (MMT) for its future program planning.

Methods: We conducted a literature review of the effects of MMT in China on HIV and HCV disease burden, injecting, and sexual behaviors and drug-related harm during 2004–2015. Data synthesis and analysis were conducted to obtain the pooled estimates of parameters for a mathematical model which was constructed to evaluate the effectiveness and cost-effectiveness of the program.

Results: Based on a review of 134 articles, this study demonstrated that MMT is highly effective in reducing crime-related, high risk sexual, and injecting behaviors. The model estimated US$1,037 m which was invested in MMT from 2004 to 2015 has prevented 29,463 (15,325–43,600) new HIV infections, 130,563 (91,580–169,546) new HCV infections, 10,783 (10,380–11,187) deaths related to HIV, HCV and drug-related harm, and 338,920.0 (334,596.2–343,243.7) disability-adjusted life years (DALYs). The costs for each prevented HIV infection, HCV infection, death, and DALY were $35,206.8 (33,594.8–36,981.4), $7,944.7 ($7,714.4–8,189.2), $96,193.4 (92,726.0–99,930.2), and $3,060.6 ($3,022.0–3,100.1) respectively.

Conclusion: The Chinese MMT program has been effective and cost-effective in reducing injecting, injecting-related risk behaviors and adversities due to HIV/HCV infection and drug-related harm among drug users.

Factors Associated with Compliance among Methadone Maintenance Treatment Transfers: Evidence from Audit Records at Clinics in Guangdong, China

Methadone maintenance treatment (MMT) requires patients to intake their daily dose in person at their clinic. Therefore, transfer services are vital for patients who need temporary leave from their primary MMT clinic. However, studies have shown that transfer patients might delay return after temporary leave, leading to missed doses and putting them at risk of increased harm. In this study, we aimed to explore the transfer rates and factors associated with MMT patients who delayed return during a transfer period. In this retrospective analysis, we used audit records from the web-based management system from six MMT clinics in Guangdong, China. Multilevel logistic regression and multilevel Poisson regression analyses were used to examine the factors associated with patients who delayed return to their primary MMT clinic. A total of 459 people used the transfer system 2940 times between January 2006 and December 2016. Of those, patients delayed return to their primary MMT clinic 1199 times (40.78%). Patients who transferred regularly had poor compliance rates with MMT treatment. Those who once dropped out from and then re-enrolled in MMT were more likely to delay return. Most patients (82.71%) who used the transfer service for “work” were more likely to prolong their delay length. The findings highlight that a more flexible transfer system would minimize inconvenience to the patients.

Struggling to achieve a 'normal life': A qualitative study of Vietnamese methadone patients

BACKGROUND

Methadone maintenance treatment, initially introduced in Vietnam for HIV harm reduction, has marked a significant switch in the country's drug policy - from addiction as a moral issue to addiction as a brain disease. After the some initial outstanding achievements, the programme is facing a high dropout rate that threatens both goals of HIV prevention and drug treatment. This sociological study, as part of an HIV intervention research project, explores the challenges and opportunities that individuals who use drugs are faced with in relation to addiction treatment.

METHODS

A qualitative study among drug users with and without methadone maintenance treatment experiences recruited by peer outreach workers. We conducted 58 in-depth interviews and 2 focus groups between 2016 and 2017.

RESULTS

The start of treatment brought about significant feelings of success as heroin use was no longer compulsive. However, being in treatment programmes is also challenging with respect to continuing the recovery process. Barriers to retention include a popular fear of methadone as another harmful drug, a feeling of dependence related to the current practices of methadone treatment programmes and a poor therapeutic relationship. In the face of such challenges, the two major motivations that keep patients in care come from the desire to completely break up with heroin and the pursuit of family happiness.

CONCLUSION

The current practices of methadone programmes pose challenges to patients' recovery efforts from addiction and threaten treatment retention. Prompt interventions are needed to help Vietnam attain its objective of providing better care for larger vulnerable populations.

An intervention to improve provider-patient interaction at methadone maintenance treatment in China

BACKGROUND

This study evaluated an intervention aiming to improve methadone maintenance therapy (MMT) service providers' interaction with their patients in China.

METHODS

Sixty-eight MMT clinics were randomized to either an intervention or a control condition. Providers in the intervention group attended three group training sessions to enhance their communication skills. Trained providers were encouraged to practice the taught communication skills through provider-initiated individual sessions with their patients. A total of 418 service providers completed assessments from baseline to 24-month. Linear mixed-effects regression models were used to compare self-reported short-term and sustained improvement in provider-patient interaction between the intervention and the control conditions.

RESULTS

The intervention group service providers perceived significantly greater short-term and sustained improvement in provider-patient interaction compared to the control group service providers (estimated difference (±SE): 1.20 (0.24) and 1.35 (0.33), respectively; p-values < 0.0001). Providers' baseline job satisfaction was significantly associated with a greater perceived improvement in provider-patient interaction for both periods (reg. coef. (±SE): 0.02 (0.01) and 0.04 (0.01) for short-term and sustained periods, respectively; p-values < 0.01).

CONCLUSION

Study findings suggest that the intervention could be beneficial for improving perceived provider-patient interaction in MMT programs. Service providers' job satisfaction should be addressed in training programs for the improvement of provider-patient interaction.

HIV infection in Xi'an, China: epidemic characterization, risk factors to false positives and potential utility of the sample-to-cutoff index to identify true positives using Architect HIV Ag/Ab combo

Background

In China, although tremendous efforts has been made, the HIV/AIDS is still not controlled.

Objectives

The study was carried out to determine the epidemic of HIV infection in Xi’an, analyse false positives (FP) risk factors and potential utility of sample-to-cutoff index to identify true positives using Architect HIV Ag/Ab Combo.

Methods

A retrospective review for HIV screening by Architect HIV Ag/Ab Combo was performed in a teaching hospital in Xi’an between 2015 and 2016. The prevalence of HIV, positive predictive value (PPV) at different cut-off indexices (COI) were calculated. The epidemic of infections and risk factors for FP results were investigated.

Results

In the study, the HIV prevalence and FP rate of Architect HIV Ag/Ab Combo were 0.076 and 46.08%, respectively. The Han Chinese, males and people aged < 40 years accounted for the majority of infections (98.29, 76.07 and 73.5%, respectively). 85.47% of the infections were transmitted through sexual contact (35.04% of male homosexual and 50.43% of heterosexual). COI at 1–10, 10–30 and ≥ 30, the PPVs were 0, 50 and 100%, respectively. The independent risk factors for FP, i.e., pregnancy and malignancy had a statistically significant association with FP (p < 0.05), and age had a very strong statistically significant association with FP (p < 0.001).

Conclusions

In Xi’an, sexual contact was the most important transmission mode for HIV, and the infections were predominantly identified in Han Chinese, males, young and middle-aged people. For Architect HIV Ag/Ab Combo, it can achieve 100% of PPV with COI ≥30, and the age was strongly statistically associated with FP.

An intervention trial targeting methadone maintenance treatment providers to improve clients' treatment retention in China

BACKGROUND

Service providers including doctors, nurses, and other healthcare professionals play an essential role in methadone maintenance treatment (MMT). This study evaluated the impact of an intervention targeting MMT providers on their clients' treatment retention.

METHODS

This study was conducted in 68 MMT clinics in five provinces of China with 36 clients randomly selected from each clinic. The clinics were randomized to intervention or control condition. The MMT CARE intervention started with group sessions to enhance providers' communication skills. The trained providers were encouraged to conduct individual sessions with clients to promote treatment engagement. The outcomes, which include client retention (main outcome) and their reception of provider-delivered individual sessions (process outcome), were measured over a 24-month period.

RESULTS

Significantly fewer intervention clients dropped out from MMT than control clients during the study period (31% vs. 41%; p < 0.0001). Dropout hazard was significantly lower in the intervention condition compared to the control condition (HR = 0.71, 95% CI: 0.57, 0.89). More intervention clients had individual sessions than control clients (93% vs. 70%; p < 0.0001). Having individual sessions was associated with a significantly lower dropout hazard (HR = 0.30, 95% CI: 0.23, 0.40). The intervention clients had a significantly lower dropout hazard than the control clients if they started the individual sessions during the first six months (HR = 0.68, 95% CI: 0.51, 0.90).

CONCLUSIONS

The MMT CARE intervention focusing on provider capacity building has demonstrated efficacy in reducing clients' treatment dropout. This study sheds light on MMT service improvement in China and other global community-based harm reduction programs.

Duration of Human Immunodef iciency Virus Infection at Diagnosis among New Human Immunodef iciency Virus Cases in Dehong, Yunnan, China, 2008-2015

Background:

On diagnosis of human immunodeficiency virus (HIV) infection, a person may have been infected already for many years. This study aimed to estimate the duration of HIV infection at the time of diagnosis.

Methods:

Newly diagnosed HIV cases in Dehong, China, from 2008 to 2015 were studied. Duration of infection at the time of diagnosis was calculated using the first CD4 cell count result after diagnosis and a CD4 depletion model of disease progression. Multiple linear regression analysis was used to investigate the associated risk factors.

Results:

A total of 5867 new HIV cases were enrolled. Overall, mean duration of infection was 6.3 years (95% confidence interval [CI]: 6.2, 6.5). After adjusting for confounding, significantly shorter durations of infection were observed among participants who were female (beta: −0.37, 95% CI: −0.64, −0.09), Dai ethnicity (beta: −0.28, 95% CI: −0.57, 0.01), and infected through injecting drug use (beta: −1.82, 95% CI: −2.25, −1.39). Compared to the hospital setting, durations were shorter for those diagnosed in any other settings, and compared to 2008, durations were shorter for those diagnosed all years after 2010.

Results:

A total of 5867 new HIV cases were enrolled. Overall, mean duration of infection was 6.3 years (95% confidence interval [CI]: 6.2, 6.5). After adjusting for confounding, significantly shorter durations of infection were observed among participants who were female (beta: −0.37, 95% CI: −0.64, −0.09), Dai ethnicity (beta: −0.28, 95% CI: −0.57, 0.01), and infected through injecting drug use (beta: −1.82, 95% CI: −2.25, −1.39). Compared to the hospital setting, durations were shorter for those diagnosed in any other settings, and compared to 2008, durations were shorter for those diagnosed all years after 2010.

Conclusion:

Although the reduction in duration of infection at the time of diagnosis observed in Dehong was significant, it may not have had a meaningful impact.

Effect of community-based extension clinics of methadone maintenance therapy for opiate-dependent clients: A prospective cohort study in Dehong Prefecture, Yunnan Province of China

Methadone maintenance therapy (MMT) is effective in treatment of opiate dependents. However, there is a gap between the coverage of standard MMT clinics and the need of opiate dependents. Establishment of extension clinics of methadone maintenance therapy (EMMT) will increase the coverage and improve MMT accessibility. We implemented a prospective cohort study to understand the effects of establishment of community-based EMMT clinics comparing with MMT clinics in Yunnan Province.A total of 462 opiate-dependent clients were interviewed from the community-based EMMT clinics and standard MMT clinics located in 5 counties of Mangshi, Ruili, Longchuan, Yingjiang, and Lianghe in Yunnan Province. The information on the demographic characteristics, drug risk behaviors, quality of life (QOL), and urine testing results for morphine of the clients was collected and compared between the EMMT and MMT clinics. A survival analysis method was utilized to know the retention situation of the newly enrolled clients with Kaplan-Meier method during 9 months treatment.Among the EMMT clients, 96.9% were male; 31.4% were Han; 61.4% were married; 39.0% had primary school education; 95.5% lived with their family or relatives; 96.9% who arrived the clinic less than 15 min; 52.9% had used drugs for more than 10 years; and 16.7% injected drug. After 9 months therapy, there was no difference in the changes of life quality such as physical and psychological features, social relationships, environmental function, and total QOL and well-being between those of EMMT and MMT clinics. The positive detection rate of urine-morphine testing among newly enrolled clients of EMMT clinics decreased as the period of treatment lengthened. The average time of retention for newly enrolled EMMT clients who are still receiving the treatment was 175 days. And the average time from initiations to drop-out of treatment for newly enrolled EMMT clients was 122 days. The 9-month retention rates of the clients were 52.1% and 60.9% at EMMT and MMT clinics, respectively.The effect on EMMT retention was the same as that of MMT. Establishment of EMMT clinics was an effective strategy to expand the coverage of MMT and increase the retention of opiate dependents in the rural areas of the counties.

Treatment for HIV prevention study in southwestern areas of China

Background

China has ambitious to achieve significant reductions in HIV transmission and HIV-related mortality by adopting the World Health Organization's “Treat All” approach. Such a prevention strategy is needed future study on regional scale.

Methods

An observational cohort study of HIV epidemiology and treatment databases was used to study the effectiveness of antiretroviral therapy on the transmission of HIV in serodiscordant couples in Guangxi of China.

Results

A total of 7713 couples were entered into the cohort study analysis which included 1885 couples in the treatment-naive cohort and 5828 couples in the treated cohort. During the follow-up of 18985.29 person-years from 2003 to 2014, the average incidence of HIV was 2.4 per 100 person-years (95% CI 2.1–2.6). HIV seroincidence rate was significantly higher among the treatment naive group (4.2 per 100 person-years, 3.7–4.8) compared with the on treatment group (1.6 per 100 person-years, 1.3–1.8). An overall 45% reduction in risk of HIV transmission among serodiscordant couple was associated with ART treatment (adjusted Hazard Ratio [HR] 0.55, 95% Confidence Interval [CI] 0.44–0.69). Treatment prevention had significantly effectiveness for most baseline characteristics of index partners, such as for male, female, age above 25 years, education below high school, farmer, infected by heterosexual intercourse.

Conclusion

Treatment-as-prevention can be implemented in the real-world on a national or regional scale, but ART adherence and comprehensive harm reduction while implementing this strategy require further study.

Influence of social network on drug use among clients of methadone maintenance treatment centers in Kunming, China

AIMS

To examine drug use behavior of clients attending Methadone Maintenance Treatment (MMT) programs and its relationship with the clients' social network characteristics.

DESIGN

Cross-sectional study.

SETTING

Four MMT clinics in Kunming, Yunnan province, China.

PARTICIPANTS

324 consecutive MMT clients.

MEASUREMENTS

A structured, self-completed questionnaire on background characteristics and existing social network. Current drug use was assessed by urine test for opiate metabolites.

ANALYSIS

The association between client's social network characteristics and their own current drug use behavior is analysed using multiple logistic regression adjusting for socio-demographic characteristics. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) are obtained to give the strength of the associations.

FINDINGS

MMT clients were more likely to concurrently use heroin while attending MMT if their social network had any of the following characteristics: more than half of the members were older than them (AOR = 1.03, 95% CI = 1.00,1.06), any member had a high level of influence on them (AOR = 6.47, 95% CI = 2.86,14.65) and any member joined them in using drugs (AOR = 1.94, 95% CI = 1.04,3.63). Having a social network member who could provide emotional support (AOR = 0.11, 95% CI = 0.03,0.35), having a spouse and/or child in their social network (AOR = 0.44, 95% CI = 0.24,0.81) and having a social network member with a high level of closeness (AOR = 0.28, 95% CI = 0.09,0.90) were associated with a decreased odds of heroin use.

CONCLUSION

Social networks who could provide MMT clients with emotional support and a close relationship were significant factors for reducing the risk of concurrent drug use among clients attending MMT clinics in Kunming, China. Behavioral interventions should address the role of family and social network members in providing support to these clients.

Cost of provision of opioid substitution therapy provision in Tijuana, Mexico

BACKGROUND

Mexico recently enacted drug policy reform to decriminalize possession of small amounts of illicit drugs and mandated that police refer identified substance users to drug treatment. However, the economic implications of drug treatment expansion are uncertain. We estimated the costs of opioid substitution therapy (OST) provision in Tijuana, Mexico, where opioid use and HIV are major public health concerns.

METHODS

We adopted an economic health care provider perspective and applied an ingredients-based micro-costing approach to quantify the average monthly cost of OST (methadone maintenance) provision at two providers (one private and one public) in Tijuana, Mexico. Costs were divided by type of input (capital, recurrent personnel and non-personnel). We defined "delivery cost" as all costs except for the methadone and compared total cost by type of methadone (powdered form or capsule). Cost data were obtained from interviews with senior staff and review of expenditure reports. Service provision data were obtained from activity logs and senior staff interviews. Outcomes were cost per OST contact and cost per person month of OST. We additionally collected information on patient charges for OST provision from published rates.

RESULTS

The total cost per OST contact at the private and public sites was $3.12 and $5.90, respectively, corresponding to $95 and $179 per person month of OST. The costs of methadone delivery per OST contact were similar at both sites ($2.78 private and $3.46 public). However, cost of the methadone itself varied substantially ($0.34 per 80 mg dose [powder] at the private site and $2.44 per dose [capsule] at the public site). Patients were charged $1.93-$2.66 per methadone dose.

CONCLUSIONS

The cost of OST provision in Mexico is consistent with other upper-middle income settings. However, evidenced-based (OST) drug treatment facilities in Mexico are still unaffordable to most people who inject drugs.

Service providers' adherence to methadone maintenance treatment protocol in China

BACKGROUND

Methadone maintenance treatment (MMT) programs have expanded rapidly in China during the last decade. However, variance in service providers' practice may have an impact on the quality of care received by the patients. This study examined Chinese service providers' adherence to the MMT protocol and its associated factors.

METHODS

The study used baseline data from a randomized intervention trial implemented in MMT clinics in five provinces of China. The data were collected from January 2012 to August 2013. A total of 418 service providers from 68 MMT clinics participated in the study. Demographic and job-related characteristics were collected. The providers' adherence to the MMT protocol, MMT knowledge, negative attitudes towards people who use drugs (PWUD), and perceived institutional support were assessed.

RESULTS

The average adherence score was 36.7 ± 4.3 (out of 9-45). Fewer providers adhered to the protocol items where communications with patients or families were required. After controlling for potential confounders, adherence to the MMT protocol was positively associated with perceived institutional support (standardized β = 0.130; p = 0.0052), and negatively associated with prejudicial attitudes towards PWUD (standardized β = -0.357; p < 0.0001). Reception of national-level MMT training was not associated with higher level of adherence to protocol.

CONCLUSION

The findings suggest the potential benefits of providing institutional support to MMT providers to enhance their level of adherence to the MMT protocol. Intervention effort is needed to reduce negative attitudes towards PWUD among MMT service providers to achieve greater consistency with best-practice recommendations.

Racial/Ethnic Differences in Prevalence Trends for Heroin use and Non-Medical use of Prescription Opioids Among Entrants to Opioid Treatment Programs, 2005-2016

Recent data suggest an increase in use of heroin and non-medical use of prescription opioids (POs) in the United States, but it is unclear if these trends are consistent across racial/ethnic groups. In a nationwide prevalence study, 69,140 patients newly admitted to an opioid treatment program (OTP) completed a brief self-administered survey of past month heroin use and PO misuse from January 2005 through September 2016. We calculated heroin use and PO misuse prevalence rates, and prevalence rate ratios of Black and Latino OTP entrants compared to White entrants over time. Initially, Black and Latino respondents reported much higher prevalence of heroin use and much lower prevalence of PO misuse than White respondents. Heroin use increased among White respondents, while it decreased among Black respondents, resulting in rates that were no longer significantly different. PO misuse prevalence decreased among White respondents while it increased among Black respondents, but remained significantly higher among White respondents. Heroin use decreased and PO misuse increased among Latino respondents during the late 2000s, but these trends largely reversed in more recent years. Among OTP entrants, racially/ethnically disparate rates of heroin use, and to a lesser extent, of PO misuse have become more similar over time. These trends were stronger when analysis was restricted to OTP entrants who either had no previous OTP history or were younger. To understand potential impacts of interventions to deter PO misuse and to maximize the effectiveness of OTPs it is important to consider potential changes in opioid use across racial/ethnic groups.

Educational and Behavioral Counseling in a Methadone Maintenance Treatment Program in China: A Randomized Controlled Trial

INTRODUCTION

Methadone maintenance treatment (MMT) programs have been rapidly scaled up nationwide in China in recent years, and psychosocial intervention measures, including counseling, were recommended for improving the outcomes of MMT. However, the effectiveness of counseling in MMT programs remains controversial. This study investigated the efficacy of educational and behavioral counseling (EBC) mode in an MMT program in China.

METHODS

A total of 125 eligible participants were randomized to EBC or a control group. Patients in the EBC group received weekly, manual-guided, group educational counseling for 8 weeks and individual behavioral counseling for the next 8 weeks. Patients in the control group received standard methadone maintenance treatment as usual (TAU).

RESULTS

During the 16-week trial, the EBC group showed better treatment attendance (P = 0.022) and a greater increase in knowledge regarding heroin addiction (P = 0.001) and MMT (P = 0.005) than did the TAU group. Between the two groups, there were no significant differences regarding drug abstinence and reduction of risky behaviors.

CONCLUSION

EBC affiliated with MMT improved patients' cognition and adherence to treatment, facilitating their successful recovery.

CLINICAL TRIAL REGISTRATION

ChiCTR-IOR-15006673: http://www.chictr.org.cn.

Report on Provider-Client Interaction From 68 Methadone Maintenance Clinics in China

Provider-client interaction is an integral of clinical practice and central to the delivery of high-quality medical care. This article examines factors related to the provider-client interaction in the context of methadone maintenance treatment (MMT). Data were collected from 68 MMT clinics in China. In total, 418 service providers participated in the survey. Linear mixed effects regression models were performed to identify factors associated with provider-client interaction. It was observed that negative attitude toward drug users was associated with lower level of provider-client interaction and less time spent with each client. Other factors associated with lower level of interaction included being female, being younger, being a nurse, and fewer years in medical field. Higher provider-client interaction was associated with provider reported job satisfaction. The findings of this study call for a need to address provider negative attitudes that can impact provider-client interaction and the effectiveness of MMT. Future intervention efforts targeting MMT providers should be tailored by gender, provider type, and medical experiences.

Spatial distribution of HIV, HCV, and co-infections among drug users in the southwestern border areas of China (2004-2014): a cohort study of a national methadone maintenance treatment program

Background

A methadone maintenance treatment (MMT) program to curb the dual epidemics of HIV/AIDS and drug use has been administered by China since 2004. Little is known regarding the geographic heterogeneity of HIV and hepatitis C virus (HCV) infections among MMT clients in the resource-constrained context of Chinese provinces, such as Guangxi. This study aimed to characterize the geographic distribution patterns and co-clustered epidemic factors of HIV, HCV and co-infections at the county level among drug users receiving MMT in Guangxi Zhuang Autonomous Region, located in the southwestern border area of China.

Methods

Baseline data on drug users’ demographic, behavioral and biological characteristics in the MMT clinics of Guangxi Zhuang Autonomous Region during the period of March 2004 to December 2014 were obtained from national HIV databases. Residential addresses were entered into a geographical information system (GIS) program and analyzed for spatial clustering of HIV, HCV and co-infections among MMT clients at the county level using geographic autocorrelation analysis and geographic scan statistics.

Results

A total of 31,015 MMT clients were analyzed, and the prevalence of HIV, HCV and co-infections were 13.05%, 72.51% and 11.96% respectively. Both the geographic autocorrelation analysis and geographic scan statistics showed that HIV, HCV and co-infections in Guangxi Zhuang Autonomous Region exhibited significant geographic clustering at the county level, and the Moran’s I values were 0.33, 0.41 and 0.30, respectively (P < 0.05). The most significant high-risk overlapping clusters for these infections were restricted to within a 10.95 km² radius of each of the 13 locations where P county was the cluster center. These infections also co-clustered with certain characteristics, such as being unmarried, having a primary level of education or below, having used drugs for more than 10 years, and receptive sharing of syringes with others. The high-risk clusters for these characteristics were more likely to reside in the areas surrounding P county.

Conclusions

HIV, HCV and co-infections among MMT clients in Guangxi Zhuang Autonomous Region all presented substantial geographic heterogeneity at the county level with a number of overlapping significant clusters. The areas surrounding P county were effective in enrolling high-risk clients in their MMT programs which, in turn, might enable people who inject drugs to inject less, share fewer syringes, and receive referrals for HIV or HCV treatment in a timely manner.

Methadone maintenance-lessons from two systems in China

In Hong Kong, methadone maintenance treatment (MMT) was launched in the 1970s, almost 30 years before the counterpart programme’s inauguration in Mainland China. Both were established in response to perceived public crises—addiction-related crime and HIV outbreak, respectively—and both are now regular services under two systems in the same country. Effectiveness of MMT in achieving the stated goals was evident in each case and provides useful lessons on strategies for dealing with the varied concerns related to illicit drug use. Today, with changing patterns of drug addiction, increasing competition for resources, and changing attitudes towards addiction and its treatment, the two MMT systems are confronted with similar challenges to achieve sustainability.

Trends and factors in human immunodeficiency virus and/or hepatitis C virus testing and infection among injection drug users newly entering methadone maintenance treatment in Guangdong Province, China 2006-2013: a consecutive cross sectional study

OBJECTIVES

To assess trends and related factors in HIV and/or hepatitis C virus (HCV) antibody testing and infection among injection drug users (IDUs) newly entering methadone maintenance treatment (MMT) in Guangdong Province, China.

METHOD

Consecutive cross sectional surveys were conducted in 14 MMT clinics from July 2006 to December 2013 in Guangdong Province, China. IDUs were excluded if they were re-enrolled or referred from other MMT clinics. Trend tests were used to examine HIV and/or HCV testing and infection, sociodemographic characteristics, drug use related behaviours and the past 3 month sexual behaviours on enrolment. Multivariate logistic regression was used to identify correlates of HIV and/or HCV testing and infection.

RESULTS

7539 IDUs with an average age of 35.6±6.2 years were newly enrolled with a history of injection for an average of 11.8±4.9 years. The average frequency of injection before enrolment had been increasing. HIV, HCV and HIV/HCV dual testing increased from 2006 to 2013 (p_trend<0.001). However, all three types of infections remained stable (p_trend>0.05) until reaching a peak in 2011, excluding the first year. Associating with fellow drug users 1-4 times during the past month, injecting for 15+ years and having multiple sexual partners during the past 3 months predicted higher percentages for HIV and/or HCV testing (p<0.05), while those injecting 4+ times per day in the past month and those who had ever shared needles were less likely to take both tests (p<0.05). Having multiple sexual partners, a longer duration of injection drug use and sharing needles or sharing more frequently were major risk factors for HIV, HCV and HIV/HCV co-infection (p<0.05).

CONCLUSIONS

The prevalence of HIV and HCV were high and quite stable among new IDU entrants in MMT. Publicising MMT, routine screening, and behavioural and structural interventions is needed.

Increased synthetic drug abuse and trends in HIV and syphilis prevalence among female drug users from 2010-2014 from Beijing, China

The objective of this study was to monitor the trend of addiction drug use and its relationship with sexually transmitted infections (STIs) among female drug users (FDUs). Serial cross-sectional surveys were conducted during 2010-2014 among FDUs in Beijing to collect information on addiction drug usage, sexual behaviors, and STI prevalence. Characteristics were analyzed and compared between traditional and synthetic drug users among FDUs by logistic regression method. A total of 3859 FDUs were surveyed during 2010-2014, with the median age being 32.7 years old. The proportion of synthetic drug users among FDUs increased from 43.7% in 2010 to 70.7% in 2014. Compared with traditional drug users, synthetic drug users were younger (P < 0.001), lacked education (P < 0.001), were unmarried (P < 0.001), and were non-local residents (P < 0.001). No significant difference was found with condom usage during sexual activity between traditional and synthetic drug FDUs. However, the engagement of commercial sexual activities (P < 0.001) and syphilis prevalence (P < 0.001) among synthetic drug users were significantly higher than traditional drug users. Synthetic drug abuse appears to be correlated with commercial sex behavior and higher syphilis prevalence among FDUs. Tailored strategies on health education to curb the prevalence of synthetic drug abuse are urgently needed in Beijing.

Evaluation of a community-based integrated heroin addiction treatment model in Chinese patients

In this study, we analyzed the efficacy and feasibility of a community-based integrated heroin addiction treatment model in Chinese patients. The 210 heroin addicts belonging to six Chinese communities received an integrated biopsychosocial intervention that included pharmacological treatment, counseling and social assistance. High proportions of study participants were retained at the 12-month (91.9%; 193/210) and 24-month (88.1%; 185/210) follow-up visits. The number of morphine-positive subjects declined from 61.4% at baseline to 36.2% and 30.5% (Q=52.01; P<0.001) after 12 and 24 months, respectively. The crime rate decreased from 32.4% at baseline to 2.2% and 1.6% (Q=7.84; P<0.001) after 12 and 24 months, respectively. The number of patients that were employed increased from 24.3% at baseline to 37.8% and 50.8% after 12 and 24 months, respectively (Q=41.68; P<0.001). Addiction-related issues and mental health status improved according to Addiction Severity Index (ASI) and Symptom Checklist-90 (SCL-90). We therefore conclude that this community-based, integrated heroin addiction treatment model is highly feasible with high treatment retention, reduced drug use, a lower crime rate, improved health and increased employment.

Positive percentages of urine morphine tests among methadone maintenance treatment clients with HIV/AIDS: a 12-month follow-up study in Guangdong Province, China

OBJECTIVE

We aimed to assess the positive percentages of urine morphine tests and correlates among methadone maintenance treatment (MMT) clients with HIV/AIDS in Guangdong, China.

SETTING

Fourteen MMT clinics located in nine cities of Guangdong were chosen as study sites.

PARTICIPANTS

In this study, we reviewed 293 clients with opioid dependence, who were HIV seropositive, 18 years or older, provided informed consent and had at least 10 records of urine morphine tests during the study period.

PRIMARY AND SECONDARY OUTCOME MEASURES

The positive percentages of urine morphine tests were calculated and underlying predictors were estimated.

RESULTS

The highest positive percentage (95.9%) was observed in the first month. After excluding the highest percentage in the first month, the average positive percentage was 40.9% for month 2 to month 12. Positive percentages of urine morphine tests that were <20%, 20-60% and >80% were 25.4%, 36.1% and 38.5% respectively. Lower percentages of continued heroin use were associated with being young (OR_≤30=0.31, 95% CI 0.12 to 0.78; OR_31-=0.44, 95% CI 0.20 to 1.00), and financial sources depending on family or friends (OR=0.55, 95% CI 0.32 to 0.93). Higher percentages of continued heroin use were associated with being unemployed (OR=1.99, 95% CI 1.13 to 3.49) and poor MMT attendance (OR_<20%=3.60, 95% CI 1.55 to 8.33; OR_20%-=2.80, 95% CI 1.48 to 5.33).

CONCLUSIONS

High positive percentages of urine morphine tests remain prevalent among MMT clients with HIV/AIDS in Guangdong. The present findings have implications for taking effective measures to facilitate attendance in order to decrease heroin use and ultimately improve the effectiveness among these sub-group MMT clients.

Re-entry and related predictors among HIV-infected clients receiving methadone maintenance treatment in Guangdong province, China

This study examined the re-entry characteristics and related predictors among HIV-infected methadone maintenance treatment (MMT) clients in Guangdong, China. Data on HIV-infected MMT clients was obtained from the clinic MMT registration system in Guangdong. Of the 653 participants, only 9.0% remained in the MMT program until the end of the study. For the drop-outs, 70.0% returned to MMT at least once by the end of the study. Re-entry was independently associated with marital status (OR_{never married} = 2.24, 95% CI: 1.02-4.93; OR_{married currently} = 2.34, 95% CI: 1.05-5.22), being unemployed (OR = 1.92, 95% CI: 1.12-3.27), lower positive percentages of urine tests (OR_<40% = 4.08, 95% CI: 2.21-7.54; OR_40%-80% = 2.52, 95% CI: 1.39-4.56), higher maintenance doses (OR = 3.78, 95% CI: 2.21-7.54)and poorer MMT attendance percentages (OR_<20% = 282.02, 95% CI: 62.75-1268.11; OR20-49% = 20.75, 95% CI: 10.52-40.93; OR50-79% = 6.07, 95% CI: 3.44-10.73). A higher re-entry frequency was independently associated with lower education level (ORjunior high school = 0.49, 95% CI: 0.26-0.93), average drug use times less than twice (OR = 0.64, 95% CI: 0.41-1.00), lower positive percentages of urine tests (OR = 0.39, 95% CI: 0.22-0.70) and poorer percentages of MMT attendance (OR<20% = 7.24, 95% CI: 2.99-17.55; OR20-49% = 14.30, 95% CI: 5.94-34.42; OR50-79% = 6.15, 95% CI: 2.55-14.85). Re-entry and repeated re-entry were prevalent among HIV-infected MMT clients in Guangdong, underscoring the urgent needs of tailored interventions and health education programs for this population.

Expanded antiretroviral treatment, sexual networks, and condom use: Treatment as prevention unlikely to succeed without partner reduction among men who have sex with men in China

Background

To project the impact of partner reduction on preventing new HIV infections among men who have sex with men (MSM) under varying conditions of enhanced HIV testing and treatment (T&T) and condom use in Beijing, China.

Methods and findings

A complex network model was fitted to predict the number of new HIV infections averted from 2014 to 2023 under four scenarios of sexual behavior risk reduction (S)—S1: Male sexual partners decrease (reduced by a random value m from 1–50) while condom use increases (risk constant p is a random value between 0.2 and 1]); S2: Both sexual partners and condom use decrease (m 1, 50; p 1, 1.8); S3: Sexual partners reduce (m 1, 10) while condom use increases or decreases (p 0.2, 1.8); S4: Only MSM with ≥100 male sexual partners reduce their partners (m 1, 50) while condom use increases (p 0.2, 1).

HIV prevalence will reach 23.2% by 2023 among Beijing MSM if T&T remains at the 2013 level. The three most influential factors are: T&T coverage; partner reduction (m); and the background risk (p). Under scenarios 1–4 of sexual behavioral changes with enhanced T&T interventions, the cumulative HIV new infections prevented over the 10 years will be 46.8% for S1 (interquartile range [IQR] 32.4%, 60.1%); 29.7% for S2 (IQR 18.0%, 41.4%), 23.2% for S3 (IQR 12.2%, 37.0%) and 11.6% for S4 (IQR 4.0%, 26.6%), respectively. The reproduction number R₀ could drop below 1 if there were a substantial reduction of male sexual partners and/or expanded condom use.

Conclusion

Partner reduction is a vital factor within HIV combination interventions to reduce HIV incidence among Beijing MSM, with substantial additional benefits derived from condom use. T&T without substantial partner reduction and increased condom use is less promising unless its implementation were extremely (and improbably) efficient.

Cost-effectiveness of Methadone Maintenance Treatment Centers in Prevention of Human Immunodeficiency Virus Infection

BACKGROUND

Acquired immune deficiency syndrome (AIDS) is one of the greatest social health problems in many communities in the twenty-first century. Methadone maintenance treatment (MMT) could decrease HIV infection among injection drug users (IDU). The main aim of this paper was to determine the cost-effectiveness of the governmental MMT program to prevent human immunodeficiency virus (HIV) infection among IDU.

METHODS

This analytical study was performed through a before-after assessment during a one-year period. Using census sampling, 251 IDU referred to the public MMT program of Kerman, Iran, were selected. The expenditures of MMT centers were calculated in the view of government (public sector). The cost-effectiveness was calculated using TreeAge software.

FINDINGS

MMT centers averted 86 new cases of HIV infection. The total cost of centers was US$471 per client in the year. The share of IDU from current expenditures was 35% and from capital expenditures was 32%. Also, methadone per capita for each person who injected drug was US$514. Per capita expenditure of HIV drug treatment was estimated US$8535 per year. Incremental cost effectiveness ratio (ICER) was US$2856 per year, which means governmental MMT program is cost-effective according to the World Health Organization (WHO) criteria.

CONCLUSION

MMT centers are cost-effective in preventing HIV infection and the access to this program should be facilitated for IDU.

Tobacco and alcohol use among drug users receiving methadone maintenance treatment: a cross-sectional study in a rural prefecture of Yunnan Province, Southwest China

OBJECTIVE

To estimate the prevalence of ever, current and heavy tobacco and alcohol use and their correlates among patients undergoing methadone maintenance treatment (MMT).

DESIGN

Cross-sectional study.

SETTING

The study was conducted in all of the 5 MMT clinics in Dehong Prefecture, China.

PARTICIPANTS

2121 (81.6%) eligible MMT participants were included in the study population.

ANALYSIS

Ordinal logistic regression was used to estimate the ORs and their 95% CIs.

RESULTS

The overall prevalence of ever, current and heavy smoking was 98.6%, 97.8% and 66.3%, respectively; while that of ever, current and hazardous alcohol drinking was 86.6%, 58.6% and 16.6%, respectively. Among HIV-infected participants, the proportions of those experiencing harmful effects of tobacco and alcohol on AIDS were 53.6% and 72.5%, respectively, and 16.9% and 49.3% had ever tried to quit after diagnosis with HIV. After adjusting for potential confounders, heavier smokers and more hazardous drinkers were more likely to be men, older and less educated. Ethnic minorities were less likely to heavily smoke, but more likely to engage in hazardous drinking. In addition, hazardous drinking was negatively associated with longer years of MMT and HIV infection. Moreover, heavier smoking (OR_≥2=2.08, 95% CI 1.16 to 3.73) and more hazardous drinking (OR_≥2=2.46, 95% CI 1.53 to 3.97) were positively associated with having multiple sexual partners, and both were positively associated with each other.

CONCLUSIONS

The prevalence of tobacco and alcohol consumption was extraordinarily high among MMT participants in China, suggesting the urgent need of enhancing MMT patients' awareness of the harmful effects of tobacco and alcohol consumption and implementing comprehensive education and effective intervention programmes.

Reliability and validity of the Treatment Outcome Profile among patients attending methadone maintenance treatment programs in Kunming, China

BACKGROUND & OBJECTIVE

Substance misuse has been a major health and social issue worldwide and has become an important public health issue in China over the past two decades. Methadone maintenance treatment (MMT) has been proved worldwide by large bodies of research to be one of the most effective practices for illicit drug users. The Treatment Outcome Profile (TOP) was developed in 2007 by the UK National Treatment Agency (NTA). It has been proved to be a reliable instrument for outcome measure. This study aim to develop the Chinese version of the Treatment Outcome Profile (TOP), and to assess whether TOP is a reliable outcome measure that can be recommended for use in Chinese MMT program.

METHODS

The Chinese version of TOP was translated and revised based on the English version of TOP. Psychometric properties of TOP were evaluated through face-to-face interviews in 197 patients who had been attending methadone maintenance treatment clinics in Kunming city, Yunnan Institute for Drug Abuse, for less than three months. Patients were interviewed by 3 trained interviewers. Reliability and validity of the instrument were analyzed by measures including test-retest and inter-rater reliability, concurrent validity and change sensitivity. Concurrent validity was assessed by comparing the scores from TOP with scores obtained from validated clinometric instruments. Self-reported opiate use was compared with results of urine analysis. Change sensitivity was judged by t-tests and chi-square tests.

RESULTS & CONCLUSIONS

About 67% of the 197 interviewers were male and 33% were female. Test-retest reliability of TOP scores (after 10 days interval) were good (K=0.65 to 0.95), inter-rater correlations (ICC) ranged from 0.7 to 0.9, and the criterion validity ranged from 0.72 to 0.88. TOP covers a large scope of problems encountered by drug users needed for treatment. The Chinese version of TOP is a reliable and valid assessment tool.

HIV cause-specific deaths, mortality, risk factors, and the combined influence of HAART and late diagnosis in Zhejiang, China, 2006-2013

To examine patterns of human immunodeficiency virus (HIV) cause-specific deaths, risk factors, and the effect of interactions on mortality, we conducted a retrospective cohort study in Zhejiang, China, from 2006 to 2013. All data were downloaded from the acquired immune deficiency syndrome (AIDS) Prevention and Control Information System. The Cox proportional hazards model was used to assess predictors of cause-specific death. The relative excess risk due to interaction and ratio of hazard ratios (RHR) were calculated for correlations between HAART, late diagnosis, and age. A total of 13,812 HIV/AIDS patients were enrolled with 31,553 person-years (PY) of follow-up. The leading causes of death of HIV patients were accidental death and suicide (21.5%), and the leading cause of death for those with AIDS was AIDS-defining disease (76.4%). Both additive and multiplicative scale correlations were found between receiving HAART and late diagnosis, with RERI of 5.624 (95% CI: 1.766-9.482) and RHR of 2.024 (95% CI: 1.167-2.882). The effects of HAART on AIDS-related mortalities were affected by late diagnosis. Early detection of HIV infection and increased uptake of HAART are important for greater benefits in terms of lives saved.

Mortality and virological failure among HIV-infected people who inject drugs on antiretroviral treatment in China: An observational cohort study

OBJECTIVE

HIV-infected people who inject drugs (PWID) have a disproportionally low rate of access to antiretroviral therapy (ART). We aimed to assess the impact of ART on 12-month mortality and virological failure of HIV-infected PWID in China, stratified by methadone maintenance treatment (MMT) and active drug use status.

METHODS

HIV-infected PWID who initiated ART at 29 clinics in 2011 were enrolled and followed in this prospective cohort study. Kaplan-Meier curves and log-rank tests were used to compare the survival probability. Risk factors for mortality and virological failure were evaluated by Cox proportional hazards models and logistic regression analyses.

RESULTS

A total of 1,633 participants initiated ART. At the time of initiation, 324 were on MMT, 625 were engaged in active drug use, and 684 had discontinued drug use but were not on MMT. At the 12-month follow-up, 80.3% remained on ART, 13.5% had discontinued ART, and 6.2% had died. Among the MMT group, active drug use group, and drug abstinent group, we observed all-cause mortality of 4.9%, 12.0%, and 1.5% and virological suppression of 51.9%, 41.1%, and 68.7%, respectively. Factors associated with both mortality and virological failure were drug use status, unemployment, and treatment facility type.

CONCLUSION

For HIV-infected PWID receiving ART, engagement in MMT and discontinuation of drug use were more likely to be associated with lower mortality and virological failure compared with active drug use. In order to maximize the clinical impact of ART, HIV treatment programs in China should be further integrated with MMT and social services.

HIV seroconversion and risk factors among drug users receiving methadone maintenance treatment in China: A qualitative study

OBJECTIVE

We sought to explore the experiences of drug users in China who were recently diagnosed with HIV infection while engaged in methadone maintenance treatment (MMT) and to better understand their perceptions of MMT, HIV risk, and HIV prevention.

METHODS

We recruited clients of MMT clinics in Chongqing and Kunming who had a baseline HIV-negative test result upon entry to MMT and had been diagnosed with HIV within the past 12 months. We conducted semi-structured qualitative interviews and thematic data analysis to identify situations and factors that increased HIV risk.

RESULTS

Among the 27 participants who were interviewed, 15 believed their infection was due to injection drug use, 7 attributed their infection to sexual contact, and 5 were unsure as to how they became infected. High risk behaviors were common; 18 participants continued to use drugs during treatment, and 10 engaged in unprotected sex. Common themes were the difficulty of drug abstinence despite receiving MMT, social pressure to continue using drugs, and low knowledge of effective HIV prevention measures.

CONCLUSION

While MMT is effective in reducing drug usage and needle sharing, many clients remain at risk of HIV infection due to continued injection drug use and unprotected sex. Clients may benefit from additional counseling on HIV prevention methods as well as structural interventions to increase the availability of clean injection equipment.

How clients' during-treatment motivations relate to their perceptions and impressions of methadone maintenance treatment: A multilevel analysis of a cross-sectional survey in Guangdong Province, China

BACKGROUND

Much evidence has suggested the positive effect of methadone maintenance treatment (MMT) on mitigating adverse outcomes caused by opioid use. Pretreatment motivations are associated with clients' engagement, retention, and outcomes in drug use treatment. However, motivation is mutable, and few MMT researchers have considered during-treatment motivations and associated multilevel factors.

OBJECTIVE

We aimed to investigate during-treatment motivations and clinic- and individual-level associated factors among MMT clients in Guangdong Province, China.

METHODS

Stratified random sampling was used to select 12 MMT clinics in Guangdong Province. Between December 2011 and January 2012, a total of 802 respondents were surveyed about their motivation and multilevel factors using the following instruments: the Texas Christian University (TCU) Treatment Motivation Scales, the impression-of-detoxification scale, the National MMT Data Management System of China, and structured questionnaires. Multilevel models were employed to conduct the univariate and multivariate analyses of the factors associated with during-treatment motivations for MMT.

RESULTS

The means ± SD (95% CI) of clients' during-treatment motivations (Desire for Help and Treatment Readiness) were 2.89±0.56 (2.85, 2.93) and 2.28±0.57 (2.24, 2.32). Multilevel analyses showed that clients' educational level, perceptions, and impressions of MMT; and clinics' supportive family assistance and closing time were significantly associated with during-treatment motivations for MMT (P<0.05).

CONCLUSIONS

During-treatment motivation may play a significant role in the success of MMT. There is a need for improving motivation among Chinese MMT clients, and the knowledge of associated factors may guide more effective program in the future.

Concurrent Heroin Use and Correlates among Methadone Maintenance Treatment Clients: A 12-Month Follow-up Study in Guangdong Province, China

Objective: To assess concurrent heroin use and correlates among Methadone Maintenance Treatment (MMT) clients in Guangdong Province, China. Method: Demographic and drug use data were collected with a structured questionnaire, and MMT information was obtained from the MMT clinic registration system in Guangdong. Human immunodeficiency virus (HIV-) and hepatitis C virus (HCV) infected status and urine morphine results were obtained from laboratory tests. Logistic regressions were employed to investigate the factors associated with concurrent heroin use. Results: Among the 6848 participants, 75% continued using heroin more than once during the first 12 months after treatment initiation. Concurrent heroin use was associated with inharmonious family relationship (OR (odds ratio) = 1.49, 95% CI (confidence intervals): 1.24–1.78), HIV positivity (OR = 1.25, 95% CI: 1.01–1.55), having multiple sex partners (OR = 1.34, 95% CI: 1.07–1.69), having ever taken intravenous drugs (OR = 0.81, 95% CI: 0.69–0.95), higher maintenance dose (OR = 1.13, 95% CI: 1.01–1.28) and poorer MMT attendance (OR_<20% = 1.32, 95% CI: 1.13–1.53; OR_20%– = 1.33, 95% CI: 1.14–1.54; OR_50%– = 1.69, 95% CI: 1.44–2.00). Among those who used heroin concurrently, the same factors, and additionally being older (OR_35– = 1.26, 95% CI: 1.11–1.43; OR_≥45 = 1.63, 95% CI: 1.30–2.05) and female (OR = 1.60, 95% CI: 1.28–2.00), contribute to a greater frequency of heroin use. Conclusions: Concurrent heroin use was prevalent among MMT participants in Guangdong, underscoring the urgent needs for tailored interventions and health education programs for this population.

Baseline HCV Antibody Prevalence and Risk Factors among Drug Users in China's National Methadone Maintenance Treatment Program

BACKGROUND

Hepatitis C virus (HCV) is the most common viral infection among injecting drug users worldwide. We aimed to assess HCV antibody prevalence and associated risk factors among clients in the Chinese national methadone maintenance treatment (MMT) program.

METHODS

Data from 296,209 clients who enrolled in the national MMT program between March 2004 and December 2012 were analyzed to assess HCV antibody prevalence, associated risk factors, and geographical distribution.

RESULTS

Anti-HCV screening was positive for 54.6% of clients upon MMT entry between 2004 and 2012. HCV antibody prevalence at entry declined from 66.8% in 2005 to 45.9% in 2012. The most significant predictors of HCV seropositivity were injecting drug use (adjusted odds ratio [AOR]: 8.34, 95% confidence interval [CI]: 8.17-8.52, p<0.0001) and a history of drug use ≥9 years (AOR: 2.01, 95% CI: 1.96-2.06, p<0.0001). Being female, of Uyghur or Zhuang ethnicity, and unmarried were identified as demographic risk factors (all p-values<0.0001). Of the 28 provincial-level divisions included in the study, we found that 5 divisions had HCV antibody prevalence above 70% and 20 divisions above 50%. The HCV screening rate within 6 months after MMT entry greatly increased from 30.4% in 2004 to 93.1% in 2012.

CONCLUSIONS

The current HCV antibody prevalence remains alarmingly high among MMT clients throughout most provincial-level divisions in China, particularly among injecting drug users and females. A comprehensive prevention strategy is needed to control the HCV epidemic among MMT clients in China.

A Smartphone Application Supporting Recovery from Heroin Addiction: Perspectives of Patients and Providers in China, Taiwan, and the USA

Smartphone-based interventions are increasingly used to support self-monitoring, self-management, and treatment and medication compliance in order to improve overall functioning and well-being. In attempting to develop a smartphone application (S-Health) that assists heroin-dependent patients in recovery, a series of focus groups (72 patients, 22 providers) were conducted in China, Taiwan, and the USA to obtain their perspectives on its acceptance and potential adoption. Data were analyzed according to the Diffusion of Innovation (DOI) theory of characteristics important to the adoption of innovation. Important to Relative Advantage, USA participants cited S-Health's potential ability to overcome logistical barriers, while those in China and Taiwan valued its potential to supplement currently limited services. In terms of Compatibility, participants across sites reported recovery needs and goals that such an application could be helpful in supporting; however, its utility during strong craving was questioned in China and Taiwan. Important factors relevant to Complexity included concerns about smartphone access and familiarity, individualization of content, and particularly in China and Taiwan, participants wanted assurance of privacy and security. The study results suggest a general acceptance, but also indicate cultural variations in access to therapeutic and other social support systems, legal repercussions of substance use, societal perceptions of addiction, and the role of family and other social support in recovery. Taking these factors into consideration is likely to increase diffusion as well as effectiveness of these smartphone-based interventions.

Risk Factors for Loss to Follow-Up among People Who Inject Drugs in a Risk Reduction Program at Karachi, Pakistan. A Case-Cohort Study

INTRODUCTION

Retention of male people who inject drugs (PWIDs) is a major challenge for harm reduction programs that include sterile needle/syringe exchange in resource-limited settings like Pakistan. We assessed the risk factors for loss to follow-up among male PWIDs enrolled in a risk reduction program in Karachi, Pakistan.

METHODS

We conducted a prospective cohort study among 636 HIV-uninfected male PWIDs enrolled during March-June 2009 in a harm reduction program for the estimation of incidence rate. At 24 months post-enrollment, clients who had dropped out of the program were defined as lost to follow-up and included as cases for case-cohort study.

RESULTS

The median age of the participants was 29 years (interquartile range: 23-36). Active outreach accounted for 76% (483/636) of cohort recruits. Loss to follow-up at 24 months was 25.5% (162/636). In multivariable logistic regression, younger age (AOR: 0.97, 95% CI: 0.92-0.99, p = 0.028), clients from other provinces than Sindh (AOR: 1.49, 95% CI: 1.01-2.22, p = 0.046), having no formal education (AOR: 3.44, 95% CI: 2.35-4.90, p<0.001), a history of incarceration (AOR: 1.68, 95% CI: 1.14-2.46, p<0.008), and being homeless (AOR: 1.47, 95% CI: 1.00-2.19, p<0.049) were associated with loss to follow-up.

CONCLUSIONS

Our cohort retained 74.5% of male PWIDs in Karachi for 24 months. Its loss to follow up rate suggested substantial ongoing programmatic challenges. Programmatic enhancements are needed for the highest risk male PWIDs, i.e., younger men, men not from Sindh Province, men who are poorly educated, formerly incarcerated, and/or homeless.

The effectiveness of compulsory drug treatment: A systematic review

BACKGROUND

Despite widespread implementation of compulsory treatment modalities for drug dependence, there has been no systematic evaluation of the scientific evidence on the effectiveness of compulsory drug treatment.

METHODS

We conducted a systematic review of studies assessing the outcomes of compulsory treatment. We conducted a search in duplicate of all relevant peer-reviewed scientific literature evaluating compulsory treatment modalities. The following academic databases were searched: PubMed, PAIS International, Proquest, PsycINFO, Web of Science, Soc Abstracts, JSTOR, EBSCO/Academic Search Complete, REDALYC, SciELO Brazil. We also searched the Internet, and article reference lists, from database inception to July 15th, 2015. Eligibility criteria are as follows: peer-reviewed scientific studies presenting original data. Primary outcome of interest was post-treatment drug use. Secondary outcome of interest was post-treatment criminal recidivism.

RESULTS

Of an initial 430 potential studies identified, nine quantitative studies met the inclusion criteria. Studies evaluated compulsory treatment options including drug detention facilities, short (i.e., 21-day) and long-term (i.e., 6 months) inpatient treatment, community-based treatment, group-based outpatient treatment, and prison-based treatment. Three studies (33%) reported no significant impacts of compulsory treatment compared with control interventions. Two studies (22%) found equivocal results but did not compare against a control condition. Two studies (22%) observed negative impacts of compulsory treatment on criminal recidivism. Two studies (22%) observed positive impacts of compulsory inpatient treatment on criminal recidivism and drug use.

CONCLUSION

There is limited scientific literature evaluating compulsory drug treatment. Evidence does not, on the whole, suggest improved outcomes related to compulsory treatment approaches, with some studies suggesting potential harms. Given the potential for human rights abuses within compulsory treatment settings, non-compulsory treatment modalities should be prioritized by policymakers seeking to reduce drug-related harms.

Evaluation of an implementation of methadone maintenance treatment in China

BACKGROUND

Methadone maintenance treatment (MMT) reduces the harms of opioid use disorder and is being rapidly scaled-up in China. This study evaluated the real-world implementation of MMT system in Wuhan, China.

METHODS

Data extracted from electronic medical records collected in 2010 on 8811 patients were used to compute for each patient indices of the prescribed and consumed daily methadone doses, an adherence index, dose adjustments following missed doses, the rates of opiate positive urine tests, self-reported drug use, injection drug use (IDU), and the duration of MMT exposure.

FINDINGS

The modal daily doses prescribed were 60 mg and above for 68.5% of patients. Adherence was variable: 51% of patients attended less than 60% and 26% attended 80-100% of their treatment days; and patients with long MMT exposure had significantly higher adherence rates than patients with short MMT exposure. The differences between doses dispensed immediately before and after the interruption in dosing days ranged from 0 to 7 mg, independently of the length of the interruption or the prescribed dosing level. The overall rate of opiate positive tests was 20%; 45% of patients had at least one opiate positive test; 29% reported past month drug use and 53% of them reported past month IDU. Adherence and MMT exposure duration correlated significantly with the proportion of opiate negative urine tests (r=0.355, p<0.001; r=0.351, p<0.001, respectively). Treatment for males and females was comparable.

CONCLUSIONS

Provision of safe methadone dosing after absences and improving daily attendance are identified as priority improvement areas.

Trends of HIV subtypes and phylogenetic dynamics among young men who have sex with men in China, 2009-2014

To investigate the origins of HIV transmission and phylogenetic dynamics among men who have sex with men (MSM), a total of 1205 newly diagnosed HIV-infected 16-25 year-olds were recruited in 13 provinces across China between 2009 and 2014. Based on phylogenetic analyses of partial pol sequences, HIV-1 subtypes including CRF01_AE (45.3%), CRF07_BC (37.8%), subtype B (6.1%), and B' (3.7%), as well as some other recombinants (7.1%) were identified. In addition to two distinct CRF01_AE clusters [cluster 4 (33.7%, 406/1205) and cluster 5 (7.1%, 85/1205)], we identified a new CRF07_BC cluster (cluster 1) (36.0%, 434/1205), which entered Chinese MSMs in 2004, and had been rapidly spreading since about 2004, which indicating the third wave of the HIV epidemic among the population. Moreover, two new clusters of CRF_01B recombinants were found in this study. The complexities of HIV subtypes and recombinants strongly supports the necessity for a comprehensive study about risk behaviors and their relationship with increasing HIV epidemic subtypes among the MSM group. Implementation and evaluation of comprehensive harm reduction strategies in Chinese MSM are urgently needed.

Geographical variations of risk factors associated with HCV infection in drug users in southwestern China

Hepatitis C virus (HCV) has become a global public health problem. Many studies have been conducted to identify risk factors for HCV infection. However, some of these studies reported inconsistent results. Using data collected from 11 methadone clinics, we fit both a non-spatial logistical regression and a geographically weighted logistic regression to analyse the association between HCV infection and some factors at the individual level. This study enrolled 5401 patients with 30·0% HCV infection prevalence. The non-spatial logistical regression found that injection history, drug rehabilitation history and senior high-school education or above were related to HCV infection; and being married was negatively associated with HCV infection. Using the spatial model, we found that Yi ethnicity was negatively related to HCV infection in 62·0% of townships, and being married was negatively associated with HCV infection in 81·0% of townships. Senior high-school education or above was positively associated with HCV infection in 55·2% of townships of the Yi Autonomous Prefecture. The spatial model offers better understanding of the geographical variations of the risk factors associated with HCV infection. The geographical variations may be useful for customizing intervention strategies for local regions for more efficient allocation of limited resources to control transmission of HCV.

Investigation of Repeat Client Drop-Out and Re-Enrolment Cycles in Fourteen Methadone Maintenance Treatment Clinics in Guangdong, China

OBJECTIVE

Client adherence is vital for effective methadone maintenance treatment (MMT). This study explores the pattern and associated factors of client adherence, drop-out and re-enrolment in the Chinese MMT programme over the period of 2006-2013.

METHODS

This retrospective study was conducted in 14 MMT clinics in Guangdong Province, China. We employed Kaplan-Meier survival analysis to estimate the rates of drop-out and re-enrolment of MMT clients and multivariate Cox regression to identify associated factors.

RESULTS

Among 1,512 study participants, 79% have experienced 'drop-out' during the 7-year study period. However, 82% 'dropped-out' clients resumed treatment at a later time. Low education level (junior high or below versus otherwise, HR = 1.21, 1.05-1.40), low methadone dosage in the first treatment episode (<50 ml versus ≥50 ml, HR = 1.84, 1.64-2.06) and higher proportion of positive urine test (≥50% versus<50%, HR = 3.72, 3.30-4.20) during the first treatment episode were strong predictors of subsequent drop-outs of the participants. Among the 'dropped-out' clients, being female (HR = 1.40, 1.23-1.60), being married (HR = 1.19, 1.09-1.30), and having a higher proportion of positive urine tests in the first treatment episode (≥50% versus<50%, HR = 1.35, 1.20-1.51) had greater likelihood of subsequent re-enrolment in MMT. Clients receiving lower methadone dosage (first treatment episode <50 ml versus ≥50 ml, HR = 1.12, 1.03-1.23; the last intake before drop-out <50 ml versus ≥50 ml, HR = 1.16, 1.04-1.30) were also more likely to re-enrol.

CONCLUSION

Persistent cycling in-and-out of clients in MMT programmes is common. Insufficient dosage and higher proportion of positive urine samples in the first treatment episode are the key determinants for subsequent client drop-out and re-enrolment. Interventions should target clients in their early stage of treatment to improve retention in the long term.

Sexual and reproductive health risks amongst female adolescents who use amphetamine-type stimulants and sell sex: a qualitative inquiry in Yunnan, China

BACKGROUND

China, as other Southeast Asian countries, has witnessed an increased use in amphetamine-type stimulants (ATS) amongst urban youth. Amongst female adolescents who both sell sex and use ATS, risk behaviours are compounded resulting in even poorer health outcomes. However, limited knowledge exists on ATS use patterns and ATS-related risk behaviours, particularly in this context. This research aimed to improve the understanding of these issues amongst female adolescents who use ATS and sell sex, and to inform future programming.

METHOD

This study utilised monthly focus group discussions (four in total) with the same study participants in Yunnan, China. From within a drug-treatment programme, female adolescents who reported both a history of drug use and selling sex were purposively enrolled in the study.

RESULTS

Participating adolescent females were aged 17-19 years and were all internal-migrants with low literacy. All reported polydrug use (mainly methamphetamine and heroin, whereas ecstasy and ketamine have been infrequently employed). Being less informed about risks of drug use and lack of sexual and reproductive health knowledge seemed to contribute to problematic drug use, rough and prolonged sexual intercourse, inconsistent condom use and ineffective contraceptive practice. For their income, participants largely relied on selling sex, which was frequently coupled with drug sharing services to clients. However, despite the practices, women did not self-identify as sex workers, and therefore did not think that existing intervention services targeting female sex workers were relevant to them. Moreover, criminalization and stigmatisation of drug use and selling sex impeded their access to care services.

CONCLUSION

Current harm reduction and HIV/sexually transmitted infection (STI) prevention services are unlikely to address the demand of female adolescents engaged in drug use and commercial sex. Our findings highlight that a comprehensive and coordinated harm reduction and sexual and reproductive health response should be conducted involving these most vulnerable adolescents.