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Background The National Institutes of Health has funded HPTN 058: A Phase III randomized controlled trial to evaluate the efficacy of drug treatment in prevention of HIV infection among opiate dependent injectors (“the 058 Trial”). The trial will be conducted at Heng Chien, Guangxi Zhuang Autonomous Region, Urumqi, Xinjiang Uighur Autonomous Region of China and Chiang Mai, Thailand. Recognizing the potential for injection drug users (IDUs) to be exposed to excess risk of arrest or other negative legal consequences by virtue of their participation in the research study, the HPTN 058 protocol requires the annual monitoring of law and its implementation related to IDUs participating in the trial. To assess the risks to IDUs of participating in the clinical trial, the HPTN 058 Protocol Team commissioned this report.
Research Procedures Laws related to possible research risk were collected and analyzed by a qualified Chinese lawyer using standard legal research methods. National and local laws were collected in nine domains: drug use (including drug control laws, syringe laws, needle exchange programs and drug treatment); HIV-specific criminal exposure or transmission; criminal justice/procedure; right to health care and right to HIV treatment; reportability of HIV, AIDS, and STDs; HIV testing laws; privacy of medical information; anti-discrimination provisions, and any other laws that influence risk or stigma among drug users in a significant way.
Research Procedures • The qualitative research team was trained on the applicable law and research procedures prior to conducting interviews. The researchers identified and recruited 44 key informants at each of the two study sites. The research protocol was reviewed and approved by the applicable Institutional Review Boards at Temple University and the China Centers for Disease Control. • The RPA identifies three types of key informants: 1) systems participants who have a good overall view of police/health/drug systems which may impact on the transmission of HIV among IDUs; 2) interactor participants who interact with IDUs on a day to day basis and are able to provide information about how each system works at a practical level; and 3) IDU participants who describe their daily interaction with law enforcement, as well as the legal, public health, and drug treatment systems with which they interact.
Specific Aims 1) To use RPA tools to document laws and law enforcement practices in Heng Chien, Guangxi Autonomous Region and Urumqi, Xinjiang Uighur Autonomous Region that may increase risks faced by the injection drug user participating in the 058 Trial; 2) To compile and deliver to the 058 Trial protocol team and other stakeholders a comprehensive risk analysis based upon the findings of the RPA that clearly indicates any evidence of elevated risk to participants that may result from their screening and enrollment in the study; 3) To recommend to the protocol team strategies to reduce or eliminate possible law and enforcement related risks posed by study screening and enrollment procedures.
Law on the Books • Drug possession, distribution and production are subject to serious punishment including the death penalty. • As to drug users, the law prescribes detention for no more than 15 days a fine of less than 2000 RMB. • Besides these penalties, the drug user could be sent to a detoxification center for 3 to 6 months’ treatment. If he/she is found to have relapsed after detoxification, he/she could be sent to a reeducation camp for up to 3 years’ rehabilitation labor. • Individual drug use/ possession of small amounts is often handled under the Security Administrative Punishment Regulations, a set of general powers exercised by the public security organs to respond to breaches of public order deemed too minor for criminal punishment.[
Compulsory Registration and Treatment • Drug users who are identified by the police are subject to registration, and may be entered into treatment or re-education through an administrative process. • The “treatment,” which in many if not most cases can include cold-turkey detoxification, lasts between three months and one year. People in treatment facilities are expected to work. In theory they are entitled to a wage but in practice their “earnings” typically go to paying the costs of their confinement. • Drug users who repeatedly relapse graduate to another sort of administrative rehabilitation facility, the Education through Labor camp. Several hundred thousand Chinese are confined in these facilities, about a third of whom are drug users.
Findings: A public health research project involving IDUs cannot operate without the cooperation of the police. • “We have a county-level AIDS Working Committee which involves Public Health, Public Security, Education, and many other departments. It is a multi-sectoral coordinating committee on AIDS. In the committee, only the Public Security Department is the one with which we keep very close touch. It is impossible for us to initiate a program involving IDUs without sufficient communication with local police in advance.” (Public Health Department Official in Heng Chien)
Findings: A public health research project involving IDUs cannot operate without the cooperation of the police. “It would be too late for you to coordinate with local police after their law enforcement activities have had negative impacts on you program. Actually, we had been negotiating with the police station long before the initiation of our program.” (Community-based syringe exchange program administrator) • “Whether or not we will go to program sites to arrest IDUs [for confinement in a detoxification center] depends on our director’s attitude. If he tells us nothing specifically about it, we will. ” (Street level police officer in Heng Chien)
Findings: if there is cooperation with police, the chance of interference at the research site is low • Clients were occasionally arrested at methadone clinics and SEPs: • “Someone reported to the police that there were drug dealers at the site. Then the police went to the site and arrested the peer educator. The epidemic prevention station officials negotiated with the police. After three days incarceration, the educator was released. From then on, police never arrest IDUs at the sites. ” (IDU-7, Heng Chien)
Findings: if there is cooperation with police, the chance of interference at the research site is low • In HPTN 033, there was no interference at either site. • “At the very beginning, both the researchers and the IDUs were afraid that the police would come to the clinic to arrest IDUs. But it did not happen.” (Researcher at Urumqi) • “In the process of HPTN033 implementation, the health sector and police developed very good relations. At first the IDUs were afraid of being arrested by the police at the program site, but it never happened. ” (Treatment staff member, Heng Chien)
Findings: street level police generally do not arrest IDUs solely for drug use. • Most of the time, the IDUs being detained can trade freedom or short-term detoxification for information. • “When we arrest an IDU, we will ask him from whom he buys drugs; who else uses drugs, and so on. To avoid being put in detoxification for a long time or penalized, the IDU will tell us what we want to know. This way, we identify drug dealers.” (Street level police officer, Heng Chien)
Findings: street level police generally do not arrest IDUs solely for drug use. • “Once you are arrested, the police will ask who sells drugs to you, where you get the money, and who uses drugs with you. If you tell them nothing, the police will use physical violence. Nearly all the IDUs being detained will be cooperative.” (IDU-9, Urumqi) • “We seldom just arrest IDUs and put them into the detoxification center. The most important reason for us to arrest them is to find out the drug dealers behind them.” (Street level police officer, Urumqi)
Findings: street level police generally do not arrest IDUs solely for drug use. • Unofficial “fines” are a way for local police officers to augment their low incomes. • “We have a very low wage and need to arrest IDUs and penalize them to make money sometimes.” (Street level police officer, Heng Chien) • “The police called my parents and asked for 2000 RMB in exchange for my release. My parents paid the money to them and I was released. ” (IDU-13, Heng Chien) • “On average, we need to hand over 3,150 RMB in exchange for release or to avoid arrest. Sometimes, we can bargain with the police.” (IDU-9, Urumqi)
Findings: street level police generally do not arrest IDUs solely for drug use. • In recent years there has been some effort by the security authorities to reduce the occurrence of informal payments. • “Formerly, the police would take money from IDUs in exchange for release or to avoid arrest. But now, they would not. They sent all the IDUs being arrested to detoxification.” (IDU-8, Urumqi) • “Before 2002, the police would take money from me in exchange for release. But once I am arrested nowadays, I will be sent to detoxification center. (IDU-15, Heng Chien)
Findings: some report research participation is protective against police action • “A few IDU participants were even released after being detained because of injecting or buying drugs.” (Public health clinician, Urumqi) • “In October 2005, Heng Chien CDC began syringe exchange programs in two villages. The peer educators were designated by both the police and the health department. The police officials promised that they would not arrest IDUs at the site.” (Researcher, Heng Chien)
Conclusions Police vigorously enforce criminal laws and detain hundreds of thousands of drug users for involuntary treatment and reeducation each year. No NGOs operate to support the health or social status of IDUs. Nonetheless, in the sites we investigated, research studies, syringe exchanges and methadone programs were able to operate with some degree of freedom from police intrusion or harassment of participants. Our policy analysis identifies two key institutional factors: 1) Public health programs for drug users have been introduced in China as a top-down measure, with strong support from the China CDC and Ministry of Health; 2) At the local level, there were health-oriented organizations that had sufficient strength and will to negotiate with police on the implementation of punitive drug control laws.
Current versions of the RPAR tools and training materials are available on the world wide web at http://www.rpar.org. Copies of the full China report and other materials are available at the RPAR Booth
Acknowledgments • Legal and qualitative data were collected using tools adapted by Scott Burris and Corey Davis from the Rapid Policy Assessment and Response toolkit. • The Rapid Policy Assessment and Response Tools were initially developed by Scott Burris, Patrica Case and Zita Lazzarini with the support of the International Harm Reduction Development Program of the Open Society Institute, and further refined under NIDA Grant # 5 R01 DA17002-02, Zita Lazzarini, Principal Investigator. • Wang Zhengzhi of Globe Law Firm, Beijing, collected relevant laws and regulations. • Qualitative research was conducted and the resulting data analyzed by Zhang Youchun, Fu Xiaoxing and local interviewers in the site cities. Zhang and Fu drafted the final report, which was edited by Burris and Davis. • The team thanks Wang Ruotao and David Metzger for their assistance in organizing and conducting the research. • Funding was provided by the HPTN through by the University of Pennsylvania.
