China has embarked on a major methadone replacement programme which not only takes addicts off heroin, but dramatically reduces the risk of HIV infection. Report by Louise Tickle.

When you have, at a conservative count, 600,000 intravenous drug users spread across a country the size of China, the risks of an HIV and AIDS epidemic escalating fast are considerable. Facing up to the sheer scale of the problem however, is an important part of mitigating, if not solving, an impending health disaster. And China, says a significant body of experts, has been very good at taking the bad news on the chin and supporting international efforts to help it manage the progress of the disease. This management has taken the form of what is known as ‘harm reduction’ – which, translated, means needle exchanges and methadone replacement programmes. The reach of the initiative (part funded by DFID) has been remarkable, says John Leigh, DFID’s Millennium Development Goals team leader in China, particularly given the enormous scale of the country.

“By 2007, 88,000 injecting drug users had been enrolled in the methadone programme, of whom 52,000 were still on treatment,” he says. “This service was being provided through 397 clinics in 22 provinces. This is impressive coverage, given that the programme was only approved for nationwide rollout in July 2006.” Methadone is taken orally, eliminating the need for a heroin user to inject. It also helps drug addicts to come off heroin without the need to go cold turkey. However, despite the painstaking collection of data to provide a strong evidence base for the effectiveness of methadone replacement in fighting the spread of HIV and AIDS, it remains controversial for certain countries – the USA, Japan and Russia most prominent among them. On a wider international stage too, it turns out that the politics involved in getting agreement for an official rollout of a controlled drug such as methadone has been extremely contentious. Countries’ own police and border control authorities tend to warn of the dangers of governments importing drugs, and are thus at odds with their colleagues in healthcare agencies who urgently want to prevent blood-borne diseases, including HIV and AIDS, from running rampant through vulnerable sectors of the population.

Sanctioning – and subsequently funding – state officials to hand out clean syringes and needles has also proved a hard nut to crack. It can be perceived as a government facilitating drug addiction. In the US, for example, this led to a long-term ban on federal funding for needle exchanges, though with the new administration, that position has just changed.

Opposition to needle exchanges is a great pity, says Leigh, as getting an intravenous drug user – effectively a criminal – to knock on the door of a government clinic and ask for methadone replacement treatment is rarely how contact is first made. A softlysoftly approach is the most effective way of persuading an addict to start to engage with healthcare workers. First, get them to inject more safely by providing clean needles and syringes, then require them to bring back their dirty equipment before handing out more. Gradually a relationship of trust is built up. After a while, a drug user might be ready to replace his or her heroin hit with methadone.

Professor Scott Burris of Temple University in Philadelphia specialises in the relationship between law, health and vulnerable populations. He says that over the past decade, China has made great strides in coming to terms with the philosophical and logistical challenges involved in introducing methadone replacement for its large number of drug addicts.

Officials have not accepted the need for needle exchanges with the same enthusiasm. Nevertheless, he observes that the national AIDS authority’s pragmatic approach to free methadone treatment suggests that those at the top have accepted the evidence that harm reduction measures are a cost-effective way of reducing the impact of HIV and AIDS. “This is due in no small measure to the advocacy and funding given by DFID and the Global Fund (to fight AIDS, Tuberculosis and Malaria) in funding the original pilots in Yunan and Sichuan province, as well as further money and support from a range of other agencies,” Professor Burris says.

“At the beginning, nobody had ever done this here, therefore those (officials) involved were taking a huge risk,” points out Qiao Jianrong, DFID’s health adviser in China. “The good thing is that given the very decentralised system here, you could get local people piloting ideas with grant support while the central authority kept one eye open and one eye closed.”

Persuading officials to promote this kind of programme, she says, cannot be done initially by citing the human rights of intravenous drug users. “It is best done by making the public health argument, then eventually officials will change their attitudes and perceptions, and understand and respect their rights better. Looking back now, it is amazing how far China has travelled in harm reduction from the policy and regulation perspective.

“Importantly, it also offers an example to the rest of world of how ideas (on harm reduction) can be transferred from one country to another at a relatively small cost. Here, those ideas are now being replicated by the government itself to achieve a nationwide methadone replacement programme led by the Chinese AIDS authority.”

Worldwide, however, observes Professor Gerry Stimson, executive director of the International Harm Reduction Association, this approach is massively under-resourced. “These measures save lives and money, as the cost of an intervention is far less than the cost of treating an infection,” he says. “But it needs 20 to 30 times more money than is currently spent.”

A political fight is being waged right now in Vienna around whether the term ‘harm reduction’ can be included in the UN declaration of intent, which is published every 10 years. Russia and Japan have explicitly opposed the phrase, and despite the new Obama regime, the US is also taking a hard line. These three nations have been backed by a number of others, but interestingly, countries don’t always practice what they preach.

Indonesia, which has also opposed the use of the phrase, plays host to a large DFID-funded harm reduction programme. So does India, which has taken the same stance. Other governments which internally fund harm reduction measures have stayed silent. All of which makes for a frustrating experience for those promoting adoption of harm reduction as an internationally endorsed principle – a principle, which, they say, has been proved in practice to save lives.

DFID’s Minister for International Development Mike Foster recently paid a visit to one of China’s biggest methadone treatment centres in the sprawling city of Chengdu. Following conversations with drug users who had progressed so well on the methadone programme that they had been trained as drug educators themselves, the minister says he was impressed. Seeing the human face of the drug treatment programme may, it turns out, make an important difference to whether the UK funding continues after DFID’s bilateral healthcare money for China runs out in 2011. “My instinct is that we will have a change of policy (on funding for China) and that might include active projects like this,” says Mike Foster.

Success in these programmes is not measured in terms of people coming off drugs altogether. Many will relapse and leave the programme, and those who continue are expected to carry on taking methadone indefinitely. But since the HIV transmission rate among needle-sharing drug users is extremely high, the more people who are prevented from sharing needles, the greater the number of HIV infections prevented. John Leigh cites a survey of methadone patients that shows those having injected within the last month had dropped from 76% to 11%.

“Infection rates among injecting drug users have not sky-rocketed, which would be expected without any harm reduction programmes in place,” Leigh says. “In contrast, prevalence among men-who-have-sex-with-men is now increasing at an alarming rate, reflecting very low rates of condom use during anal sex. However, if we can successfully control the spread of HIV among drug users, it is extremely unlikely that HIV will gain much further ground in China. The patterns of sex work are not such as to be able to fuel an epidemic. The epidemic here is still predominantly driven by injecting drug use.”

One beneficial spin-off of the methadone and needle exchange programmes, he points out, is that many drug users not currently enrolled in either of the official harm reduction programmes have been made aware of the risks and are taking steps on their own to avoid needle sharing.

The human reality of this effort is that people who were once society’s pariahs are now able to hold down jobs, rejoin their families and end the criminal behaviour they once pursued to fund their addiction. Fewer babies will be born with HIV, and fewer children will lose their parents to infectious diseases. Those working in the sector believe these are good enough reasons to include a commitment to ‘harm reduction’ in the UN’s statement of intent, which will set the tone for how the ravages of HIV and AIDS are managed internationally over the coming decade.