By Gisa Hartmann

In response to the rise of drug dependence, China has begun to embrace harm reduction,
scaling up policies such as methadone maintenance treatment (MMT) and needle
exchange programs (NEP) in a growing number of areas. This shift in policy is expressed
in the new Anti-Drug Law, which categorizes drug addiction as a medical condition rather than a criminal issue or moral failing. But how far along is the development of MMT and NEP in China, and what does the state plan
for the future? How do current policies play out for drug users on the ground? This
two-part blog will explore these and related issues.

According to government numbers (which some doctors and NGOs argue still minimize the number of people infected with HIV through blood sales and blood transfusions), China’s HIV prevalence rates are
highest among injection drug users (IDU): one article estimates that China
has at least 2 million IDU, with an overall HIV prevalence of 12%. By the
end of 2002, cases of HIV among IDU were reported in all provinces. In Yunnan and Xinjiang,
HIV prevalence is as high as 80% among the IDU population.

The central government has made a commitment to a significant scale-up of both NEP and MMT: the China Action Plan for Reducing and Preventing the Spread of HIV/AIDS (2005-2010) commits to serving at least half
of the IDU population by 2010 by establishing 1400 NEP sites and MMT clinics in cities or prefectures with more than 500 drug users.

Methadone maintenance treatment and needle exchange programs

The Chinese government approved a trial of the first
eight methadone clinics in early 2004. As in other countries, these clinics
were successful in reducing frequency of injection and high risk behavior. Clients
also reported that clinic clients engaged in less drug-related crime and were
better able to secure jobs. However, drop-out rates were up to 51%.

One possible reason for the high drop-out
rates may have been the dosage used in China at that time, which was lower than
the levels found to be optimal in other countries. China’s
early clinics also lacked other services that are included in a
comprehensive treatment approach and which help to build retention, such as psychological
counseling, additional referral services, health education, group activities,
social support and skills training.

In the same year, China also established 750 needle exchange
programs in seven provinces. A study published in 2007 found
that needle turnover was most successful where local police supported efforts
by NEP service providers. The number of NEP sites run by the Center for Disease
Control (CDC) has expanded since 2004. These facilities mainly operate during
normal working hours and rarely provide night services, vending machines or
mobile clinics – innovations that have proven successful in other countries.

Bureaucratic obstacles hinder higher
enrollment in MMT programs. These include a requirement that IDU complete
compulsory detoxification at least once before becoming eligible for MMT, and
that IDU have a local household registration (hukou 户口) in the
town where they take methadone. MMT service
providers also complain about a lack of adequate resources, lack of
institutional support, and the need for more professional training to provide
the quality and quantity of care needed by their clients.

While Beijing recently lifted
the provision that obliged IDU to provide hukou residence permits to enroll in MMT, the barrier remains in
place for China’s thousands of migrant workers in other parts of the country.
Before any in-country travel, MMT participants need to obtain referral
prescriptions from their local service station, because methadone is only dispensed
in daily dosages and has to taken in liquid form on-the-spot at the clinic to
ensure clients’ compliance with the program. While in some cases it is possible
to obtain exceptions, as in many other countries, it is illegal to take
methadone out of the country on international travel.

Drug dependence treatment vs. drug control

As in other countries, the most positive
results of harm reduction policies have been in those rare areas where health
workers are able to establish cooperation with the police. One study
published by the Chinese National Center for AIDS/STD Control and Prevention in
2007 revealed that few Chinese police see drug dependence as a medical
condition rather than a criminal offense, and some cited an individual’s
enrollment in MMT or NEP as a legitimate cause for arrest. The study noted some
cases where police have followed peer educators to meetings with IDU in order
to arrest the person who received the needle after the peer educator left. Naturally,
fear of arrest can keep IDU away from available services.

As the same study by observes, “Even
in areas where police may show passive support (inasmuch as they do not arrest
NEP users), when local or central governments launch crackdowns on drug use,
they need to fulfill their arrest quotas and NEP attendees are easy targets.”

Despite the harm reduction policies
that are also in place, China has severe policies against drug use, treating
drug use as a “social evil” which needs to be countered by mass arrests, crackdowns and forced
detoxification. Police can arrest and conduct urine test on anyone suspected of
drug use, and those who test positive may be sentenced to a minimum of two
years in a forced detoxification center.

Wolfe and Saucier estimate that over 330,000 Chinese IDU are currently detained
in such centers. The centers fall under the administrative detention system run
by the Ministry of Public Security, and meaning detainees are usually sentenced
without a trial. Compulsory detoxification centers in China have been criticized for abusive
“treatment” measures and use of forced labor. In some cases, IDU may be kept
beyond their expected release date in order to generate enough money to cover expenses
related to their stay. Other punishments can include withholding of adequate
food, sleep deprivation and forced HIV testing, results of which may not be shared
with detainees. Furthermore, harm reduction services such as methadone are not available in prisons or detoxification
centers.

The Drug Control Law which went into effect June 1, 2008 made changes to this
system. While the forced detoxification centers persist, the new law eliminates
the even harsher reeducation-through-labor sentence (formerly between 1-3
years) as a sentencing option. The law categorizes drug dependence as a disease
requiring treatment, and allows IDU arrested for the first time to recover in local
residential communities for up to three years. According to the law, compulsory
detoxification will be reserved for for people who relapse.

While these steps are positive, numerous challenges remain. First, since sentences are handed down in police
stations and not in court, it will be difficult to monitor implementation of
the new law, or to challenge a sentence. Worse, the revised law increased the
minimum forced  detoxification sentence
to two years.

Additionally, the new law does not clearly define the terms drug use, abuse and drug addiction or dependence. A “drug
addict” can be anyone registered by law enforcement agencies as a drug user
after a previous offense, as well as recreational drug users; just one single positive
urine test can be the basis for classification as a “drug addict”.

Gisa Hartmann is administrative coordinator at Asia Catalyst.