title: Coverage of harm reduction services and HIV infection: a multilevel analysis of five Chinese cities.
abstract: Since 2003, a harm reduction program for injecting drug users has been rolled out countrywide in China. It entails services for condom promotion, a needle and syringe program (NSP), and methadone maintenance treatment (MMT). However, it remains unknown if and to what extent the coverage of these services at city level is related to a reduced risk of HIV infection among drug users.
  
  
  
  We wished to quantify the extent to which city-level characteristics (such as NSP and MMT service coverage) and individual-level determinants (e.g., self-reported exposure to NSP and MMT services, knowledge, motivation, and skills) were associated with the risk of HIV infection among drug users. In 2006, we conducted an integrated serological and behavioral survey among drug users in five cities of Yunnan Province, China (N = 685), constructing a multilevel logistic regression model with drug users clustered within these cities.
  
  
  
  Drug users who reported having received NSP or MMT services were about 50% less likely to be infected with HIV than those who reported not having received them (OR 0.45, 95% CI, 0.26-0.83 for NSP and 0.48, 95% CI, 0.31-0.73 for MMT). Despite a between-city variation of HIV infection risk (ICC 0.24, 95% CI 0.08-0.54), none of the city-level factors could explain this difference. Individual-level determinants such as perceived risk of infection and use of condoms were not associated with HIV infection.
  
  
  
  Although people who had used NSP or MMT services were less likely to be HIV infected, this study found no relationship between city-level coverage of HIV prevention programs and variations in HIV infection between cities. This may have been due to the low number of cities in the analysis. Future research should include the analysis of data from a larger number of cities, which are collected widely in China through integrated behavioral and serological surveys.
authors.affiliation: Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands. q.wu@erasmusmc.nl.|School of Public Health, Kunming Medical University, Yunnan, People's Republic of China. q.wu@erasmusmc.nl.
authors.forename: Qing
authors.identifier: 0000-0003-0344-8284
authors.initials: Q
authors.lastname: Wu
authors.affiliation: Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
authors.forename: Carlijn
authors.initials: C
authors.lastname: Kamphuis
authors.affiliation: Department of Research and Development, Yunnan Provincial Red Cross Hospital, Kunming, People's Republic of China.
authors.forename: Lin
authors.initials: L
authors.lastname: Duo
authors.affiliation: School of Public Health, Kunming Medical University, Yunnan, People's Republic of China.
authors.forename: Jiahong
authors.initials: J
authors.lastname: Luo
authors.affiliation: School of Public Health, Kunming Medical University, Yunnan, People's Republic of China.
authors.forename: Ying
authors.initials: Y
authors.lastname: Chen
authors.affiliation: Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
authors.forename: Jan Hendrik
authors.initials: JH
authors.lastname: Richardus
mesh_terms: D000328:Adult; D002681:China; D002947:Cities; D015897:Comorbidity; D017280:Condoms; D005260:Female; D015658:HIV Infections / Q000453:epidemiology* / Q000517:prevention & control; D040261:Harm Reduction; D006801:Humans; D008297:Male; D008691:Methadone; D055361:Multilevel Analysis / Q000379:methods*; D018671:Needle-Exchange Programs / Q000706:statistics & numerical data; D058850:Opiate Substitution Treatment / Q000706:statistics & numerical data*; D015819:Substance Abuse, Intravenous / Q000453:epidemiology / Q000534:rehabilitation*; D014505:Urban Population / Q000706:statistics & numerical data*
chemical_list: D008691:Methadone
keywords: Behavior model; HIV infection; Harm reduction coverage; Methadone maintenance treatment; Needle and syringe program; Southwest China