China’s methadone maintenance treatment program was initiated in 2004 as a small pilot project in just eight sites. It has since expanded into a nationwide program encompassing more than 680 clinics covering 27 provinces and serving some 242 000 heroin users by the end of 2009. The agencies that were tasked with the program’s expansion have been confronted with many challenges, including high drop-out rates, poor cooperation between local governing authorities and poor service quality at the counter. In spite of these difficulties, ongoing evaluation has suggested reductions in heroin use, risky injection practices and, importantly, criminal behaviours among clients, which has thus provided the impetus for further expansion. Clinic services have been extended to offer clients a range of ancillary services, including HIV, syphilis and hepatitis C testing, information, education and communication, psychosocial support services and referrals for treatment of HIV, tuberculosis and sexually transmitted diseases. Cooperation between health and public security officials has improved through regular meetings and dialogue. However, institutional capacity building is still needed to deliver sustainable and standardized services that will ultimately improve retention rates. This article documents the steps China made in overcoming the many barriers to success of its methadone program. These lessons might be useful for other countries in the region that are scaling-up their methadone programs.

AimTo estimate the prevalence of, and identify factors associated with, depression and anxiety among communitybased methadone maintenance treatment (MMT) clients in China. Design A cross-sectional survey. Setting Nine MMT clinics, three each from three Chinese provinces (Yunnan, Anhui and Jiangsu) between October 2008 and February 2009. Participants A total of 1301 MMT clients. Measurements A questionnaire, including the Zung Self-Rating Depression Scale (SDS) and Zung Self-Rating Anxiety Scale (SAS), and on-site urine drug testing. Findings The prevalence of depression (SDS score ≥ 53) and anxiety (SAS score ≥ 50) in our sample was 38.3% [95% confidence interval (CI) = 35.7, 40.9] and 18.4% (95% CI = 16.3, 20.5), respectively, with 14.2% (95% CI = 12.3, 16.1) displaying symptoms of both. Sample prevalence rates for depression [mean = 49.69, standard deviation (SD) = 10.34] and anxiety (mean = 40.98, SD = 10.66) were higher than the national average for each (t(0.05/2, 1300) = 19.2, P < 0.001 and t(0.05/2, 1300) = 8.0, P < 0.001, respectively). Employing multi-level modelling techniques, gender (P = 0.03) and employment status (P < 0.001) were found to be associated significantly with depression in a single-level model; however, in a multi-level mixed model, only employment status (P < 0.001) was associated with depression. Gender (P = 0.03), education level (P = 0.02), marital status (P = 0.04), employment status (P < 0.001), positive urine drug test results (P = 0.02) and daily methadone dose (P < 0.001) were found to be associated significantly with anxiety in a single-level model, while only employment status (P < 0.01) and positive results for the urine drug test (P = 0.04) were associated with anxiety in a multi-level mixed model. Conclusions A considerable proportion of methadone maintenance treatment clients in China have experienced depression and anxiety during treatment. There is a need to provide tailored mental health interventions for this high-risk population.

This study identifies structural-level factors influencing methadone maintenance therapy (MMT) program implementation in China. Twenty-eight service providers and 560 randomly selected clients from 28 MMT clinics in the study area underwent face-to-face interviews. Number of clients, retention rate, coverage, and structural-level factors, were collected from a survey of service providers. Individual-level factors and self-reported illicit drug use information were obtained from clients. Urine specimens were collected from the client participants to test for heroin use. Clinics affiliated with the local CDC had more clients, higher retention rates, and broader coverage than those not affiliated with the CDC. Longer operating hours, incentive for compliant clients, and comprehensive services were positively associated with client recruitment and coverage. Comprehensive services and incentives for compliant clients were negatively associated with concurrent illicit drug use. Comprehensive services should be incorporated into the MMT program. Extended operating hours and incentives for compliant clients should be implemented.

ObjectiveTo assess the overall mortality of methadone maintenance treatment (MMT) clients in China and its associated factors.MethodsA total of 1,511 MMT clients, all of whom enrolled in China's first eight MMT clinics between March and December 2004, were included in this cohort study and followed for approximately six years, until June 2010. Mortality and its predictors were examined using Cox proportional hazards regression models.ResultsA total of 154 deaths were observed within 5,391 person-years (PY) of follow-up for an all-cause mortality rate of 28.6 per 1,000 PY. The leading causes of death were drug overdose (33.8%), HIV/AIDS-unrelated disease (21.4%), and HIV/AIDS (16.9%). The all-cause mortality rate of clients engaged in MMT for one year or less was roughly three times that of clients who stayed in MMT for four years or more (14.0 vs. 4.6, p<0.0001), HIV-positive subjects was nearly four times mortality rate than that of HIV-negative individuals (28.1 vs.6.8, p<0.0001). ART-naive HIV-positive subjects had approximately two times higher mortality rate than those receiving ART (31.2 vs. 17.3, <0.0001). After adjusting for confounding variables, we found that being male (HR = 1.63, CI: 1.03–2.57, p = 0.0355) and being HIV-positive (HR = 5.16, CI: 3.70–7.10, p<0.0001) were both associated with higher risk of death whereas increased durations of methadone treatment were associated with a lower risk of death (HR = 0.26, CI: 0.18–0.38, p<0.0001 for two to three years, HR = 0.08, CI: 0.05–0.14, p<0.0001 for four or more years).ConclusionOverall mortality was high among MMT clients in China. Specific interventions aimed at decreasing mortality among MMT clients are needed. Our study supports the need for keeping client at MMT longer and for expanding ART coverage and suggests the potential benefits of integrated MMT and ART services for drug users in China.

AimsTo describe the data collected by the Chinese methadone maintenance treatment (MMT) system and the characteristics of clients entering the programme. Design Descriptive study using routinely collected data from the MMT data management system for the period March 2004 and March 2010. Setting All MMT clinics in China. Participants Clients who enrolled for services between March 2004 and March 2010. Measurements Routinely collected data included: demographic information; drug use, sexual and criminal behaviours; status of infection with human immunodeficiency virus (HIV), hepatitis C virus (HCV) and syphilis; random urine-opiate test results; and the daily methadone dose received. Differences among clients by year were examined. Findings During the period examined, there were 251 974 clients attending 684 clinics in 27 provinces. Overall, the mean age was 34.4 years, 83.8% were male, 70.2% were unemployed, 75% had ever injected drugs, 17% had shared needles and 7.4% were HIV-positive. The profile of clients changed over time, with fewer HIV-positive individuals, fewer injecting drug users, fewer needle-sharers, fewer females and fewer unemployed. Half the clients dropped out within 6 months. The average final dose received was 49.4 mg. The estimated probability of interrupting treatment before 6 months was 52.5%. Conclusions The profile of clients enrolling in methadone maintenance treatment in China is continually changing and appears to be associated with reduced risk of HIV. High dropout in the programme may limit its effectiveness. The availability of a centralized, real-time data system was extremely useful for monitoring the progress of the Chinese methadone maintenance treatment programme.