Academic journal article Bulletin of the World Health Organization

Methadone Maintenance Treatment and Mortality in HIV-Positive People Who Inject Opioids in China/Therapie De Maintien a la Methadone et Mortalite Chez Les Personnes Seropositives Qui S'injectent Des Opioides En Chine/El Tratamiento De Mantenimiento Con Metadona En Seropositivos Que Se Inyectan Opiaceos En China

Academic journal article Bulletin of the World Health Organization

Methadone Maintenance Treatment and Mortality in HIV-Positive People Who Inject Opioids in China/Therapie De Maintien a la Methadone et Mortalite Chez Les Personnes Seropositives Qui S'injectent Des Opioides En Chine/El Tratamiento De Mantenimiento Con Metadona En Seropositivos Que Se Inyectan Opiaceos En China

Article excerpt

Introduction

In Asian countries, including China, most epidemics of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) have stabilized. In 2011, the estimated prevalence of HIV infection in China was 0.058%, a rate similar to or lower than that observed in neighbouring countries. Furthermore, an estimated 780 000 people were living with HIV/AIDS and 28.4% of them were thought to have been infected by injecting illicit drugs. (1) China now has the world's largest number of people who inject illicit drugs (2) and it is well known that the country's epidemic of HIV infection originated in and spread rapidly in this group because of unsafe practices, such as sharing needles. (2-4) The epidemic soon spread through commercial plasma donation, sexual contact and mother-to-child transmission. (3)

In response, since 2004 the Chinese government has implemented comprehensive strategies for treating both HIV infection and drug dependence involving, respectively, a National Free Antiretroviral Treatment Programme and a National Methadone Maintenance Treatment Programme. (1,5-7) The National Free Antiretroviral Treatment Programme (NFATP) operates in a variety of settings, including infectious disease hospitals, general hospitals and local clinics run by the Chinese Center for Disease Control and Prevention. By April 2012, the programme had provided antiretroviral therapy (ART) to a total of 166 371 HIV-positive (HIV+) patients. (8) Already, the 10-year-old programme is seeing some success: mortality rates and viral loads have decreased more among enrolled patients than among those not undergoing treatment. (9-12) Similarly, the National Methadone Maintenance Treatment Programme has reduced drug dependence and involvement in drug-related crime among clients, increased the employment rate and improved social functioning. (6) This programme has helped 357 586 opioid-dependent individuals since 2004; (8) it is, in fact, the largest network for methadone maintenance treatment in the world. (13)

In China and globally, the introduction of ART has dramatically reduced AIDS-related mortality and the rate at which HIV+ patients progress to AIDS. However, in low- and middle-income countries, the proportion of HIV+ people injecting illicit drugs who receive ART is often disproportionally low. (14) For example, people who inject illicit drugs account for an estimated 28.4% of all HIV+ individuals in China, but only 15.5% of ART patients inject illicit drugs. (1,12,15) Thus, despite the increasing availability of ART, which is a life-saving therapy, HIV-related and all-cause mortality remain high among people who inject illicit drugs and are HIV+.

Studies in various countries, including Brazil, (16) Denmark (17) and the United States of America, (18) have shown that individuals on ART who become infected with HIV by injecting illicit drugs have a higher risk of death than those infected by other transmission routes. The lower uptake of ART and the poorer outcomes observed among HIV+ people who inject illicit drugs are thought to be attributable to a variety of factors, such as delays in starting treatment, poor adherence to ART, continuing drug dependence and a high prevalence of comorbidities, such as depression and hepatitis C. (19)

Internationally, there is growing evidence that treatment of opioid dependence, such as methadone maintenance treatment (MMT), not only stabilizes drug dependence and its associated psychosocial conditions, but also promotes adherence to ART and improves virological responses among HIV+ people. (18,20-23) Although China's national ART and MMT programmes have been shown to benefit their respective target populations when assessed independently, (6,9-11,24,25) the advantages of coincident ART and MMT for HIV+ people who inject opioids have not yet been examined in China, though they have been observed in other settings. (13,20,23,26,27) The aim of this study, therefore, was to determine whether MMT reduces mortality in HIV+ people who inject opioids and are receiving ART through China's national ART programme. …

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