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EDITORIAL
doi:10.1111/add.12809
Towards ending HIV/AIDS among drug users in China
The 90-90-90 targets (i.e. by 2020, 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression) set by the Joint United Nations Programme on HIV/ AIDS (UNAIDS) has provided a clear and pragmatic road map towards ending the HIV/AIDS epidemic by 2030 [1]. Ending HIV/AIDS among key populations is the first, critically important step. In the past decade, China has made remarkable progress in scaling-up harm reduction programs [2,3]. However, both the drug use and HIV epidemics among drug users have evolved during the past decade, calling for new approaches [2,4–6]. This special issue assembles a collection of papers which describe the changing landscape of drug use and the HIV epidemic, underscoring the need to further expand access to antiretroviral therapy (ART) and quality long-term HIV care for drug users in China.
SHIFTING FROM TRADITIONAL TO SYNTHETIC DRUGS With the resurgence of drug use in China beginning in the late 1970s, the most commonly used drugs were opioids, particularly heroin. The drug use epidemic in China has evolved significantly since then, in both the number of drug users and the types of drugs used, from predominantly opioids to new types of drugs. During 2003–10, the proportion of heroin use decreased by 52.3% and synthetic drug use increased by 860.7% among newly identified drug users [7]. Heroin use decreased from 88.2% in 2003–04 to 56.8% in 2008– 10, while synthetic drug use increased from 6.5 to 40.8% during the same periods, respectively [7]. The proportion of users younger than 35 years decreased from 80.6% to 66.8% during these periods, while the proportion of women decreased from 19.1 to 15.9% [7]. National sentinel surveillance data have also shown a rapid increase in the proportion of drug users who take club drugs, from 1.3% in 2004 to 24.4% in 2011 [8]. A survey conducted among club drug users in six provinces showed that methamphetamine was the most commonly abused drug (73.9%) through non-injection routes. Of particular concern, in the past year 75.2% of users reported ever engaging in sex with multiple partners and 79.8% reported having unprotected sex after using club drugs [9]. Users of both genders reported being more likely to engage in sexual risk behavior after using club © 2014 Society for the Study of Addiction
drugs, although men were more likely to have sex with multiple sex partners, while women were more likely to engage in unprotected sex [9]. High-risk sexual behaviors associated with club drug use have increased the risk of sexual transmission of HIV among this group. Therefore, prevention and interventions targeting sexual risk behaviors for club drug users must be prioritized.
SIGNIFICANT DECLINE OF HIV INFECTION IN DRUG USERS In China, the HIV epidemic occurred initially in injecting drug users (IDUs) [4]. To curb the HIV epidemic among the drug-using population, China rapidly scaled-up both methadone maintenance treatment (MMT) and needle and syringe exchange programs (NSEP) throughout the country [2,3]. These large-scale harm reduction programs have significantly impacted the HIV epidemic among the drug-using population. A 6-year study following 251 974 clients who enrolled in MMT found a decline in the number of those who were HIV-positive, IDUs, women, unemployed or who practised needle-sharing [10]. Luo and colleagues found that NSEP non-attendees were 1.67 times more likely to be HIV-positive compared to NSEP attendees. Participation in NSEP was associated with a substantially lower risk of HIV infection among IDUs, thus expanding these programs is likely to reach and benefit more IDUs [11]. While HIV prevalence among drug users nation-wide has continued to decline, surveillance data show that the epidemic among drug users remains highly concentrated in southwestern China. In 1999, HIV prevalence peaked at 30.3% among IDUs, and then decreased gradually to 10.9% by 2011 [8]. A decline in needle sharing among IDUs from 19.5% in 2006 to 11.3% in 2011 was also observed. These dramatic changes in injecting-related risk behaviors and HIV infection among this group are due probably to the rapid scale-up of harm reduction strategies. Finally, providing ART to most, if not all, HIV-infected individuals is critical to ending HIV/AIDS. Many difficulties remain in achieving the goal of providing ART to 90% of identified HIV-infected individuals. A disproportionately low number of HIV-infected drug users receive ART [12]. However, a high proportion of HIV-infected drug users continuing in MMT access ART. These results suggest that integrating MMT and ART services (‘onestop shopping’) will increase the proportion of drug users remaining on both drug and HIV treatment [13]. Addiction, 110 (Suppl. 1), 1–3
2
Editorial
CHALLENGES TO ENDING HIV/AIDS IN DRUG USERS In the past decade, HIV infection among drug users in China declined significantly and it is likely that China will achieve the goal of halving HIV among this group by 2015 [14]. However, tremendous challenges lie ahead in moving towards ending HIV among this group. First, thousands of new infections are still caused by injecting drug use each year, particularly among those who are not covered by harm reduction services. Additionally, drug users who attend MMT or NSEP frequently drop out and continue to be at risk for HIV infection. Further, improving access to ART and management of co-infections among HIV infected drug users remains challenging [15,16]. The sustained reduction of new cases and mortality requires continuing capacity building and innovation in harm reduction strategies and integration with ART to attract more drug users, to reduce attrition and to reduce risky behaviors on a large scale [15–17]. Secondly, the sexual transmission of HIV among drug users is now considerable, particularly with the rapid increase in club drug use [7–9] and highly prevalent alcohol use [18]. However, the contribution of these forms of drug use to additional cases of sexual transmission among this population is not yet understood. China must improve its public health response through better coordination and implementation of surveillance and evidencebased research, and through multisectoral responses including screening and early intervention within the health system. This broad approach will help to identify the role and nature of these other addictions facilitating effective club drug and alcohol control strategies [18]. In conclusion, since identifying the initial outbreak, HIV prevalence among IDUs in China has declined considerably due to effective, large-scale interventions. These successes offer an example to other affected areas, particularly in rapidly scaling-up interventions for addicted populations in limited resource settings. China must build on the innovative, pragmatic and scalable solutions that defined the initial epidemic response in order to continue reducing infection among drug users, and ultimately ending HIV/AIDS in these groups. DISCLAIMER The opinions expressed in this editorial reflect the collective views of the co-authors and do not necessarily represent the official position of the National Center for AIDS/STD Control and Prevention, Chinese Center for Diseases Control and Prevention or the US Centers for Disease Control and Prevention. Declaration of Interests None. © 2014 Society for the Study of Addiction
Acknowledgements We thank Willa Dong for editorial assistance. ZUNYOU WU 1, YU WANG 2, ROGER DETELS 3 & MARC BULTERYS 4
National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China,1 Chinese Center for Disease Control and Prevention, Beijing, China,2 Department of Epidemiology, UCLA School of Public Health, Los Angeles, CA, USA,3 Global AIDS Program in China, US Centers for Disease Control and Prevention, Beijing, China4 E-mail: [email protected]; [email protected] References 1. Joint United Nations Programme on HIV/AIDS (UNAIDS). 90-90-90. An Ambitious Treatment Target to Help End the AIDS Epidemic. Report. Geneva: UNAIDS; 2014. 2. Wu Z., Sullivan S. G., Wang Y., Rotherum-Borus M. J., Detels R. The evolution of China’s response to HIV/AIDS. Lancet 2007; 369: 679–90. 3. Sullivan S., Wu Z. Rapid scale up of harm reduction in China. Int J Drug Policy 2007; 18: 118–28. 4. Wu Z., Rou K., Cui H. The HIV/AIDS epidemic in China: history, current strategies and future challenges. AIDS Educ Prev 2004; 16: 7–17. 5. National Center for AIDS/STD Control and Prevention (China CDC). 2013 HIV Sentinel Surveillance Report in China. Beijing: China CDC, National Center for AIDS/STD Control and Prevention; 2013. 6. National Center for AIDS/STD Control and Prevention (China CDC). 2013 HIV/AIDS Epidemic Estimation in China. Beijing: China CDC, National Center for AIDS/STD Control and Prevention; 2013. 7. Jia Z., Liu Z., Chu P., McGoogan J. M., Cong M., Shi J. et al. Tracking the evolution of drug abuse in China, 2003–10: a retrospective, self controlled study. Addiction 2014; 110 (Suppl. 1): 4–10. 8. Wang L., Guo W., Li D., Ding Z., McGoogan J. M., Wang N. et al. HIV epidemic among drug users in China: 1995– 2011. Addiction 2014; 110 (Suppl. 1): 20–8. 9. Bao Y., Liu Z., Li J., Zhang R., Hao W., Zhao M. et al. Club drug use and associated high-risk sexual behavior in six provinces in China. Addiction 2014; 110 (Suppl. 1): 11–9. 10. Sullivan S. G., Wu Z., Rou K., Pang L., Luo W., Wang C. et al. Who uses methadone services in China? Monitoring the world’s largest methadone program. Addiction 2014; 110 (Suppl. 1): 29–39. 11. Luo W., Wu Z., Poundstone K., McGoogan J. M., Dong W., Pang L. et al. Needle and syringe exchange programs and prevalence of HIV infection among intravenous drug users in China. Addiction 2014; 110 (Suppl. 1): 61–7. 12. Zhang F., Dou Z., Ma Y., Zhang Y., Zhao Y., Zhao D. et al. Effect of earlier initiation of antiretroviral treatment and increased treatment coverage on HIV-related mortality in China: a national observational cohort study. Lancet Infect Dis 2011; 11: 516–24. 13. Zhao Y., Shi C. X., McGoogan J. M., Rou K., Zhang F., Wu Z. Predictors of accessing antiretroviral therapy among Addiction, 110 (Suppl. 1), 1–3
Editorial
HIV-positive drug users in China’s National Methadone Maintenance Treatment Program. Addiction 2014; 110 (Suppl. 1): 40–50. 14. United Nations, General Assembly. Political Declaration on HIV/AIDS: Intensifying Our Efforts to Eliminate HIV/AIDS. New York: United Nations; 2011. 15. Liu E., Rou K., McGoogan J. M., Pang L., Cao X., Wang C. et al. Factors associated with mortality of HIV positive clients receiving methadone maintenance treatment in China. J Infect Dis 2013; 208: 442–53. 16. Zhang F., Zhu H., Wu Y., Dou Z., Zhang Y., Kleinman N. et al. HIV, hepatitis B virus, and hepatitis C virus co-infection in
© 2014 Society for the Study of Addiction
3
patients in the China National Free Antiretroviral Treatment Program, 2010–12: a retrospective observational cohort study. Lancet Infect Dis 2014; 14: 1065–72. 17. Li J., Wang C., McGoogan J. M., Rou K., Bulterys M., Wu Z. Human resource development and capacity-building during China’s rapid scale-up of methadone maintenance treatment services. Bull World Health Organ 2013; 91: 130–5. 18. Li Q., Babor T. F., Zeigler D., Xuan Z., Morisky D., Hovell M. F. et al. Health promotion interventions and policies addressing excessive alcohol use: a systematic review of national and global evidence as a guide to health-care reform in China. Addiction 2014; 110 (Suppl. 1): 68–78.
Addiction, 110 (Suppl. 1), 1–3
EDITORIAL
doi:10.1111/add.12809
Towards ending HIV/AIDS among drug users in China
The 90-90-90 targets (i.e. by 2020, 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression) set by the Joint United Nations Programme on HIV/ AIDS (UNAIDS) has provided a clear and pragmatic road map towards ending the HIV/AIDS epidemic by 2030 [1]. Ending HIV/AIDS among key populations is the first, critically important step. In the past decade, China has made remarkable progress in scaling-up harm reduction programs [2,3]. However, both the drug use and HIV epidemics among drug users have evolved during the past decade, calling for new approaches [2,4–6]. This special issue assembles a collection of papers which describe the changing landscape of drug use and the HIV epidemic, underscoring the need to further expand access to antiretroviral therapy (ART) and quality long-term HIV care for drug users in China.
SHIFTING FROM TRADITIONAL TO SYNTHETIC DRUGS With the resurgence of drug use in China beginning in the late 1970s, the most commonly used drugs were opioids, particularly heroin. The drug use epidemic in China has evolved significantly since then, in both the number of drug users and the types of drugs used, from predominantly opioids to new types of drugs. During 2003–10, the proportion of heroin use decreased by 52.3% and synthetic drug use increased by 860.7% among newly identified drug users [7]. Heroin use decreased from 88.2% in 2003–04 to 56.8% in 2008– 10, while synthetic drug use increased from 6.5 to 40.8% during the same periods, respectively [7]. The proportion of users younger than 35 years decreased from 80.6% to 66.8% during these periods, while the proportion of women decreased from 19.1 to 15.9% [7]. National sentinel surveillance data have also shown a rapid increase in the proportion of drug users who take club drugs, from 1.3% in 2004 to 24.4% in 2011 [8]. A survey conducted among club drug users in six provinces showed that methamphetamine was the most commonly abused drug (73.9%) through non-injection routes. Of particular concern, in the past year 75.2% of users reported ever engaging in sex with multiple partners and 79.8% reported having unprotected sex after using club drugs [9]. Users of both genders reported being more likely to engage in sexual risk behavior after using club © 2014 Society for the Study of Addiction
drugs, although men were more likely to have sex with multiple sex partners, while women were more likely to engage in unprotected sex [9]. High-risk sexual behaviors associated with club drug use have increased the risk of sexual transmission of HIV among this group. Therefore, prevention and interventions targeting sexual risk behaviors for club drug users must be prioritized.
SIGNIFICANT DECLINE OF HIV INFECTION IN DRUG USERS In China, the HIV epidemic occurred initially in injecting drug users (IDUs) [4]. To curb the HIV epidemic among the drug-using population, China rapidly scaled-up both methadone maintenance treatment (MMT) and needle and syringe exchange programs (NSEP) throughout the country [2,3]. These large-scale harm reduction programs have significantly impacted the HIV epidemic among the drug-using population. A 6-year study following 251 974 clients who enrolled in MMT found a decline in the number of those who were HIV-positive, IDUs, women, unemployed or who practised needle-sharing [10]. Luo and colleagues found that NSEP non-attendees were 1.67 times more likely to be HIV-positive compared to NSEP attendees. Participation in NSEP was associated with a substantially lower risk of HIV infection among IDUs, thus expanding these programs is likely to reach and benefit more IDUs [11]. While HIV prevalence among drug users nation-wide has continued to decline, surveillance data show that the epidemic among drug users remains highly concentrated in southwestern China. In 1999, HIV prevalence peaked at 30.3% among IDUs, and then decreased gradually to 10.9% by 2011 [8]. A decline in needle sharing among IDUs from 19.5% in 2006 to 11.3% in 2011 was also observed. These dramatic changes in injecting-related risk behaviors and HIV infection among this group are due probably to the rapid scale-up of harm reduction strategies. Finally, providing ART to most, if not all, HIV-infected individuals is critical to ending HIV/AIDS. Many difficulties remain in achieving the goal of providing ART to 90% of identified HIV-infected individuals. A disproportionately low number of HIV-infected drug users receive ART [12]. However, a high proportion of HIV-infected drug users continuing in MMT access ART. These results suggest that integrating MMT and ART services (‘onestop shopping’) will increase the proportion of drug users remaining on both drug and HIV treatment [13]. Addiction, 110 (Suppl. 1), 1–3
2
Editorial
CHALLENGES TO ENDING HIV/AIDS IN DRUG USERS In the past decade, HIV infection among drug users in China declined significantly and it is likely that China will achieve the goal of halving HIV among this group by 2015 [14]. However, tremendous challenges lie ahead in moving towards ending HIV among this group. First, thousands of new infections are still caused by injecting drug use each year, particularly among those who are not covered by harm reduction services. Additionally, drug users who attend MMT or NSEP frequently drop out and continue to be at risk for HIV infection. Further, improving access to ART and management of co-infections among HIV infected drug users remains challenging [15,16]. The sustained reduction of new cases and mortality requires continuing capacity building and innovation in harm reduction strategies and integration with ART to attract more drug users, to reduce attrition and to reduce risky behaviors on a large scale [15–17]. Secondly, the sexual transmission of HIV among drug users is now considerable, particularly with the rapid increase in club drug use [7–9] and highly prevalent alcohol use [18]. However, the contribution of these forms of drug use to additional cases of sexual transmission among this population is not yet understood. China must improve its public health response through better coordination and implementation of surveillance and evidencebased research, and through multisectoral responses including screening and early intervention within the health system. This broad approach will help to identify the role and nature of these other addictions facilitating effective club drug and alcohol control strategies [18]. In conclusion, since identifying the initial outbreak, HIV prevalence among IDUs in China has declined considerably due to effective, large-scale interventions. These successes offer an example to other affected areas, particularly in rapidly scaling-up interventions for addicted populations in limited resource settings. China must build on the innovative, pragmatic and scalable solutions that defined the initial epidemic response in order to continue reducing infection among drug users, and ultimately ending HIV/AIDS in these groups. DISCLAIMER The opinions expressed in this editorial reflect the collective views of the co-authors and do not necessarily represent the official position of the National Center for AIDS/STD Control and Prevention, Chinese Center for Diseases Control and Prevention or the US Centers for Disease Control and Prevention. Declaration of Interests None. © 2014 Society for the Study of Addiction
Acknowledgements We thank Willa Dong for editorial assistance. ZUNYOU WU 1, YU WANG 2, ROGER DETELS 3 & MARC BULTERYS 4
National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China,1 Chinese Center for Disease Control and Prevention, Beijing, China,2 Department of Epidemiology, UCLA School of Public Health, Los Angeles, CA, USA,3 Global AIDS Program in China, US Centers for Disease Control and Prevention, Beijing, China4 E-mail: [email protected]; [email protected] References 1. Joint United Nations Programme on HIV/AIDS (UNAIDS). 90-90-90. An Ambitious Treatment Target to Help End the AIDS Epidemic. Report. Geneva: UNAIDS; 2014. 2. Wu Z., Sullivan S. G., Wang Y., Rotherum-Borus M. J., Detels R. The evolution of China’s response to HIV/AIDS. Lancet 2007; 369: 679–90. 3. Sullivan S., Wu Z. Rapid scale up of harm reduction in China. Int J Drug Policy 2007; 18: 118–28. 4. Wu Z., Rou K., Cui H. The HIV/AIDS epidemic in China: history, current strategies and future challenges. AIDS Educ Prev 2004; 16: 7–17. 5. National Center for AIDS/STD Control and Prevention (China CDC). 2013 HIV Sentinel Surveillance Report in China. Beijing: China CDC, National Center for AIDS/STD Control and Prevention; 2013. 6. National Center for AIDS/STD Control and Prevention (China CDC). 2013 HIV/AIDS Epidemic Estimation in China. Beijing: China CDC, National Center for AIDS/STD Control and Prevention; 2013. 7. Jia Z., Liu Z., Chu P., McGoogan J. M., Cong M., Shi J. et al. Tracking the evolution of drug abuse in China, 2003–10: a retrospective, self controlled study. Addiction 2014; 110 (Suppl. 1): 4–10. 8. Wang L., Guo W., Li D., Ding Z., McGoogan J. M., Wang N. et al. HIV epidemic among drug users in China: 1995– 2011. Addiction 2014; 110 (Suppl. 1): 20–8. 9. Bao Y., Liu Z., Li J., Zhang R., Hao W., Zhao M. et al. Club drug use and associated high-risk sexual behavior in six provinces in China. Addiction 2014; 110 (Suppl. 1): 11–9. 10. Sullivan S. G., Wu Z., Rou K., Pang L., Luo W., Wang C. et al. Who uses methadone services in China? Monitoring the world’s largest methadone program. Addiction 2014; 110 (Suppl. 1): 29–39. 11. Luo W., Wu Z., Poundstone K., McGoogan J. M., Dong W., Pang L. et al. Needle and syringe exchange programs and prevalence of HIV infection among intravenous drug users in China. Addiction 2014; 110 (Suppl. 1): 61–7. 12. Zhang F., Dou Z., Ma Y., Zhang Y., Zhao Y., Zhao D. et al. Effect of earlier initiation of antiretroviral treatment and increased treatment coverage on HIV-related mortality in China: a national observational cohort study. Lancet Infect Dis 2011; 11: 516–24. 13. Zhao Y., Shi C. X., McGoogan J. M., Rou K., Zhang F., Wu Z. Predictors of accessing antiretroviral therapy among Addiction, 110 (Suppl. 1), 1–3
Editorial
HIV-positive drug users in China’s National Methadone Maintenance Treatment Program. Addiction 2014; 110 (Suppl. 1): 40–50. 14. United Nations, General Assembly. Political Declaration on HIV/AIDS: Intensifying Our Efforts to Eliminate HIV/AIDS. New York: United Nations; 2011. 15. Liu E., Rou K., McGoogan J. M., Pang L., Cao X., Wang C. et al. Factors associated with mortality of HIV positive clients receiving methadone maintenance treatment in China. J Infect Dis 2013; 208: 442–53. 16. Zhang F., Zhu H., Wu Y., Dou Z., Zhang Y., Kleinman N. et al. HIV, hepatitis B virus, and hepatitis C virus co-infection in
© 2014 Society for the Study of Addiction
3
patients in the China National Free Antiretroviral Treatment Program, 2010–12: a retrospective observational cohort study. Lancet Infect Dis 2014; 14: 1065–72. 17. Li J., Wang C., McGoogan J. M., Rou K., Bulterys M., Wu Z. Human resource development and capacity-building during China’s rapid scale-up of methadone maintenance treatment services. Bull World Health Organ 2013; 91: 130–5. 18. Li Q., Babor T. F., Zeigler D., Xuan Z., Morisky D., Hovell M. F. et al. Health promotion interventions and policies addressing excessive alcohol use: a systematic review of national and global evidence as a guide to health-care reform in China. Addiction 2014; 110 (Suppl. 1): 68–78.
Addiction, 110 (Suppl. 1), 1–3
