Skip to content

Advertisement

You're viewing the new version of our site. Please leave us feedback.

Learn more

BMC Public Health

Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

A cross-sectional study of the feasibility of pharmacy-delivered harm reduction services among people who inject drugs in Xichang, China

BMC Public Health201515:885

https://doi.org/10.1186/s12889-015-2236-x

Received: 26 March 2015

Accepted: 7 September 2015

Published: 14 September 2015

Abstract

Background

HIV prevalence is high in Liangshan, China (1.1 %). In 2012, people who inject drugs (PWID) in Xichang, the capital city, contributed to 60.0 % of the HIV infections. The goal of the current study was to examine the feasibility of implementing pharmacy-delivered harm reduction services (PDHRS) for PWID.

Methods

Face-to-face structured interviews with 403 PWID included questions on PWID’s experiences of syringe services and their specific experiences, acceptance, and potential usage of PDHRS.

Results

There were some reports of harassment/bad treatment from pharmacists (12.2 %) and police (17.6 %). Non-prescription syringe sales (NPSS) from pharmacies in single piece were the main source (82.1 %) of syringes. 72.5 % of PWID reported visiting 31.5 % of the identified pharmacies. Most (74.7 %) PWID disposed of their used syringes by throwing them away. Only one PWID brought used syringes back to a pharmacy in the past 30 days. Half of the PDHRS, such as printed materials about HIV, Hepatitis C and STIs; risk reduction services; (16.9 %) and sharps container to dispose of syringes (0.2 %) were offered by a few pharmacies (<20 % for each service). The acceptance rates among PWID toward currently offered services were high (≥91.1 %). All potential PDHRS were acceptable by most (68–95.3 %) PWID, and correspondingly 67–94.5 % of PWID reported they would use each service if offered.

Conclusions

NPSS from pharmacies provided many PWID in Liangshan with new syringes. However, disposal of used syringes was problematic. At the time of investigation, half of 16 assessed PDHRS were already available in pharmacies in Xichang. PWID were ready to use all the potential PDHRS and14 of 16 PDHRS were feasible to provide. HIV testing kits may be available in pharmacies in the future. Many pharmacy-delivered harm reduction services are feasible and acceptable among PWID in Xichang, China.

Background

The first indigenous human immunodeficiency virus (HIV) cases in China were reported among heroin users in the Yunnan province in 1989 [1]. The overall HIV prevalence (0.058 %) in China remains low, but HIV prevalence among people who inject drugs (PWID) remains high [2]. Due to country-wide responses [36], by the end of 2011, Methadone Maintenance Treatment (MMT) (738 clinics covering 13.3 % of the total PWID) and Needle Exchange Program (NEP) (over 900 sites delivering more than 12 million clean syringes annually) have been scaled up in China [4, 7, 8]. Syringe distribution rates (per PWID per year) in China are greater than the global average, including levels in the United States and Russia [8]. HIV prevalence among PWID has been decreasing from 12.0 % in 2005 [3], 9.3 % in 2009 to 6.4 % in 2011 [4]. In certain areas, such as Liangshan Yi Autonomous Prefecture (Liangshan), Sichuan province, sharing syringes and other injection equipment are still common among PWID [5, 6, 9]. Between March 2004 and December 2012, HIV prevalence among PWID from 11 methadone clinics in Liangshan was found to be 25.4 % [7].

In 2012, China accounted for approximately 20 % of the global numbers of PWID [10, 11]. Sichuan province ranked 5th in the number of PWID in China [2]; most are from Liangshan [12, 13]. Liangshan has been part of the major drug trafficking routes in China for more than 100 years, and heroin use is common in Liangshan [14]. HIV incidence in Liangshan increased dramatically, accounting for 81.5 % of the total HIV/AIDS cases in the past 5 years [15]. According to the Asian Epidemic Model, PWID accounted for 52.3 % of the HIV infections in Liangshan in 2013, and are anticipated to be responsible for 39.1 % by 2020 [16].

Providing sterile syringes to PWID is a cost effective method of HIV prevention [17]. NEP and pharmacies are the major sources of sterile syringes [18]. Yet perceived discrimination [19], internalized stigma [20], and lack of stigma management strategies [21] impede PWID from using formal health services such as NEP [20, 22, 23]. Internationally, community pharmacies have been providing services such as non-prescription syringe sales (NPSS), HIV-testing, vaccinations, educational materials, and coupon syringe programs. Other services are potentially available in pharmacies, such as providing methadone, naloxone for overdose treatment, safer injection training programs, containers to dispose of used syringes, on-site disposal, testing for hepatitis, and directly observed therapy for PWID [18, 21, 2438]. However, PWID have reported problems accessing available harm reduction services. Refusals to sell syringes and demands for picture identification or prescriptions have been documented even when purchasing syringes is legal and there is no official requirements for providing identification or a prescription [18, 29, 30, 3537].

In China, syringes are considered medical devices. Pharmacies that sell syringes are required to obtain a “Medical Devices Operation Enterprises permit”, which is issued by the provincial bureau of the Food and Drug Administration (FDA) and supervised by the Prefecture FDA [39]. In Guangxi Province, distribution of pharmacy vouchers for syringes, ampoules of sterile water for injection, and condoms has been previously tested [40]. A survey among 324 PWID from detoxification centers in Yunnan Province documented that their major sources of syringes were pharmacies and health clinics [41]. Between 2008 and 2011, NEP among 19 counties in Yunnan had been implemented at pharmacies, clinics, and through peer educators [42].

NPSS to PWID in Liangshan have not been reported in previous literature, and it was unclear whether PWID would utilize potential PDHRS. Xichang, the capital of Liangshan, has a population is more than 600,000 [6]. In 2012, the official estimated number of PWID was 2250, and drug use contributed to 60 % of HIV infections [23]. The HIV prevalence among PWID in Xichang was found to be 11.3 % [43] in 2002, 17.8 % in 2004 [44], and 18.0 % in 2012 [23]. There is one MMT clinic, three MMT outpatient service sites, and three NEP sites. In 2012, there were more than 400 pharmacies. The goal of the present study was to examine the feasibility of a range of PDHRS for PWID in Xichang.

Methods

This study was a cross-sectional study design, and the protocols were approved by both institutional review boards (IRBs) from Johns Hopkins Bloomberg School of Public Health (JHSPH) and the West China School of Public Health (WCSPH). The survey was developed as part of a multisite study on the feasibility of using pharmacies for PWID’s health services [23]. The protocol and questionnaire were initially written in English. The questionnaire was translated into Chinese, reviewed both by the US and China study team, and piloted. The survey took approximately 30 min to administer. The local collaborator, Xichang Skin Disease and Prevention Center (XSDPC), is a government agency responsible for HIV/AIDS prevention and control. The research team selected Xichang methadone clinic and detoxification center to recruit eligible PWID. The study inclusion criteria for PWID were: 1) 18 years of age or over and 2) had injected drugs within the past 30 days. From April to May, 2012, investigators from WCSPH and staff from XSDPC were trained as interviewers and conducted face-to-face structured interviews. Snowball sampling methods were used. After completing their interviews, PWID were encouraged to inform other PWID about the study. A total of 403 PWID were recruited from Xichang detoxification center (66.7 %), MMT clinic (15.6 %), communities (7.4 %), MMT outpatient service sites (6.7 %), and rehabilitation center (3.5 %). As participants volunteered for the study and came to the clinics for the interviews, response rates could not be calculated.

Before completing an interview, eligible participants provided informed consent, and 50 yuan (~USD 8) compensation was provided after completing the surveys. Condoms and safe injection supplies were provided as well as appropriate referrals. The survey questions included demographic characteristics, self-reported HIV status, methods of obtaining and disposal of syringes, experiences of syringe services in pharmacies, and the perceptions and potential utilizations of 16 potential PDHRS. The 16 PDHRS included: printed materials about HIV, Hepatitis C, and sexually transmitted infection(STI) risk reduction; blood pressure check; vaccinations for Hepatitis A and B; information about how to prevent abscesses; overdose medication (naloxone); sharps container to dispose of syringes; a written medical, drug treatment, and social service referrals; free condoms; HIV testing; training or information about how to inject safely; training or information about preventing overdoses; syringe exchange; disposal of used syringes; directly dispensing methadone; and free syringes. The response options toward potential PDHRS were binary (yes or no).

SPSS 22.0 (IBM, USA) was used for analyses. For univariate analysis, range and median for interval variables and frequencies for nominal variables were conducted. Fisher’s exact test was used for comparing the frequencies of receiving and giving used syringes among PWID and P < 0.05 as a level of statistical significance.

Results

The characteristics of 403 participants are presented in Table 1. Almost all (95.8 %) PWID had been in prison/jail or forced drug treatment; 71.0 % reported that they had been tested for HIV, and among them 70.6 % said they were HIV negative, 14.7 % HIV positive, and 14.7 % did not know their status. The earliest test among the participants was reported in 1994. Overall, 41.7 % were HIV negative, 8.7 % HIV positive, 8.7 % had been tested but did not know their status, and 29.0 % had not been tested.
Table 1

Characteristics of PWID enrolled in Xichang, China 2012 (n = 403)

Characteristic

median(range)

Age, (years)

35(17–55)

Living in Xichang, (years)

28(1–51)

Education, (years)

8 (0–16)

Income in last month, (Chinese Yuan)

2000(0–30,000)

 

No. (%)

Male Sex

353(87.6)

Ethnic group

 

 Han

213(52.9)

 Yi

180(44.7)

 others

10(2.5)

Currently enrolled in any kinds of school, college, a vocational or training program

3(0.7)

Stable housing

367(91.1)

Martial statues

 

 Married

187(46.4)

 Single

116(28.8)

 Divorced

86(21.3)

 Widowed

7(1.7)

 Separated

6(1.5)

 Other

1(0.2)

Live arrangements

 

 With parents

173(42.9)

 With sex partners

117(29.0)

 Alone

87(21.6)

 Others

25(6.2)

Employed

234(58.1)

Own a cell phone

336(83.4)

Abbreviations: People who inject drugs (PWID)

In the past 30 days, 2.7, 19.4, and 77.9 % of PWID, respectively reported “always”, “at least once”, and “never” using a used syringe; 3.5 % “always”, 25.3 % “at least once”, and 71.2 % “never” passed their syringe to someone else to use after they had used it. It is interesting to note that PWID reported receiving fewer used syringes than they distributed (Fisher’s exact test, p < 0.01).

Receiving and disposing used syringes

Most (72.0 %) PWID agreed with the statement that “it was easy to get new sterile syringes”, and a large percentage (81.1 %) reported having purchased a syringe in a pharmacy in the last 30 days, with a median of six syringes for regular purchase. The most frequent (74.7 %) method for syringe disposal was throwing syringes away, and 24.3 % reported that they left syringes where they injected. Only 1 PWID brought used syringes to a pharmacy (Table 2).
Table 2

Obtaining and disposing of syringes in the Last 30 days among PWID from Xichang, China 2012 (n = 403)

Sources of syringes

Syringes disposal

Source

No. (%)

Syringes usually obtained median(range)*

Source

No. (%)

Pharmacy

327(81.1)

6(1–180)

Throwing syringes away

302(74.7)

Medical facility

93(23.1)

6(1–500)

Left syringes where they injected

98(24.3)

Someone else obtain syringes from pharmacy

48(11.9)

3(1–100)

Buried or burned syringes

72(17.9)

NEP

36(8.9)

10(2–100)

Brought syringes to a NEP

20(5.0)

Syringe seller/drug dealer

25(6.2)

4.5(1–50)

Put syringes in a sharps container, or soda or laundry bottle, then threw it away

20(5.0)

Bought from a friend, relative, or acquaintance (PWID or non-PWID)

10(2.5)

5(2–20)

Gave syringes to someone else to take to a NEP for them

18(4.5)

Received free from a friend, relative or acquaintance (PWID or non-PWID)

10(2.5)

5(1–25)

Gave syringes to an outreach worker or peer educator

10(2.5)

From someone who said they got them at a NEP

6(1.5)

10(1–50)

Brought syringes to a pharmacy

1(0.2)

From an outreach worker

2(0.5)

21.5(8–35)

-

 

Used prescription for syringes because of diabetic or other medical condition

1(0.2)

20(20–20)

-

 

Abbreviations: People who inject drugs (PWID) needle exchange program (NEP)

*: median and range were calculated only among PWID who obtained syringes from the source

Experiences of buying syringes from pharmacies

Most (82.1 %) PWID reported having purchased a syringe in a pharmacy in the last 12 months, over half (63.5 %) reported that the minimum number of syringes that they could buy in a pharmacy in Xichang was one, and 59.3 % of participants reported the price for one syringe was one Chinese Yuan (~$0.16). Almost two-thirds (64.5 %) of PWID agreed with the statement “it’s generally hard for me to go to the pharmacy during the hours they are open.” A similar proportion (65.2 %) preferred to buy syringes at a pharmacy where they buy over-the-counter (OTC) or prescription drugs; 43.8 % reported that they used pharmacies in the same neighborhood/region where they live. There were 309 (76.7 %) PWID who named the pharmacies where they bought syringes most of time, and 124 unique pharmacies were identified. One pharmacy was frequently visited by 23(5.7 %) PWID and 31.5 % of the 124 identified pharmacies were visited by more than one PWID (Table 3).
Table 3

Frequently visited pharmacies for syringes purchase among PWID from Xichang, China 2012 (n = 309)

No. of PWID naming a specific pharmacy

No. of pharmacies named

Percentage of pharmacies named (%)

No. of PWID

Percentage of PWID

1

85

68.5

85

21.1

2

15

12.1

30

7.4

3

4

3.2

12

3.0

4

2

1.6

8

2.0

5

2

1.6

10

2.5

6

4

3.2

24

6.0

7

2

1.6

14

3.5

8

3

2.4

24

6.0

10+

7

5.6

102

25.3

total

124

100.0

309

76.7

Abbreviations: People who inject drugs (PWID) €: n = 403

When buying syringes in pharmacies in the last 12 months, 18.6 % of PWID reported that their requests were declined, and 12.2 % were harassed or treated poorly at the pharmacy (Table 4). Some (17.6 %) PWID reported that they had been stopped or poorly treated by the police near a pharmacy.
Table 4

Syringes purchase experiences in pharmacies among PWID from Xichang, China 2012 (n = 403)

 

Occurred in the last 12 months (No. (%))

Frequency in the past 30 days (median(range))£

Declined to sell syringes

75(18.6)

3(0–100)

Harassed or treated badly at the pharmacy

49(12.2)

3(0–30)

Asked what the syringes will be used for

30(7.4)

3(1–30)

Refused to sell ‘single’ syringes

12(3.0)

2(0–10)

Asked to sign a log-book or required written personal information

3(0.7)

2(1–3)

Asked to show a photo identification card

3(0.7)

1.5(1–2)

PWID refers to people who inject drugs

£: median and range were calculated only among PWID who experienced in the last 12 months

Pharmacy-delivered services

Among the 16 listed potential services in the pharmacies, eight were currently offered by ≤16.9 % of pharmacies. The most commonly offered service was printed materials about HIV, Hepatitis C, and STI risk reduction services (16.9 %), and the least common were sharps containers (0.2 %) and written medical or social service referrals (0.2 %). The acceptance rates were high among services currently offered (≥91.1 %). The eight services that were associated with harm reduction, such as HIV testing and free syringes, were not currently offered in pharmacies. The 16 potential harm reduction services were acceptable to most PWID (68–95.3 %), and most (67–94.5 %) PWID reported that they would use the service if offered (Table 5).
Table 5

Availability and feasibility for PDHRS among PWID in the last 12 months from Xichang, China 2012 (n = 403)

Service category

Services currently available (No. (%))

Potential services (No. (%))

Offered/availabe

Accepted/used

Good idea to offer

Personally use if offered

Printed materials about HIV/Hepatitis C/STIs risk reduction

68(16.9)

65(95.6)

384(95.3)

381(94.5)

Blood pressure check

45(11.2)

41(91.1)

369(91.6)

367(91.1)

Training/information about preventing overdoses

10(2.5)

10(100.0)

350(86.8)

347(86.1)

Training/information about how to inject safely

5(1.2)

5(100.0)

337(83.6)

334(82.9)

Training/information about how to prevent abscesses

3(0.7)

3(100.0)

353(87.6)

353(87.6)

Overdose medication (naloxone/narcan)

2(0.5)

2(100.0)

278(69.0)

277(68.7)

Sharps container to dispose of syringes

1(0.2)

1(100.0)

281(69.7)

276(68.5)

A written medical or social service referral

1(0.2)

1(100.0)

301(74.7)

302(74.9)

Free condoms

0

0

346(85.9)

340(84.4)

Vaccinations for hepatitis A/B

0

0

335(83.1)

326(80.9)

HIV testing

0

0

317(78.7)

308(76.4)

Free syringes

0

0

325(80.6)

322(79.9)

To dispose of used syringes

0

0

290(72.0)

285(70.7)

To exchange used syringes for new ones

0

0

287(71.2)

285(70.7)

A written drug treatment referral

0

0

280(69.5)

280(69.5)

Directly dispensing methadone

0

0

274(68.0)

270(67.0)

Abbreviations: PDHRS Pharmacy-Delivered Services, HIV human immunodeficiency virus, STIs, sexually transmitted infections

€: n = offered or available in the last 12 months

Discussion

At the time of this study, government funded detoxification center, MMT, and NEP services were available, but no government funded HIV prevention funds provided to pharmacies for harm reduction services in Xichang. The first available harm reduction service reported in this sample of PWID was HIV testing, which occurred in 1994, 5 years after the first large national HIV outbreak among PWID in Yunnan [1]. As almost all (95.8 %) PWID had been in prison or jail or forced drug treatment where HIV testing is mandatory, it was expected that over 95 % should have been tested. However the self-report HIV testing rate was only 71.0 %. Therefore, it is probable that HIV positive status was under-reported [23]. In this study, syringe sharing was lower than previously reported [9], which may be due in part to country-wide responses to HIV by increasing the levels of syringe distribution [36, 9].

Though most PWID (>90 %) were recruited from harm reduction sites, pharmacies, rather than these sites, were the main source of obtaining syringes. Pharmacies appear to be a critical and highly accessible source of syringes, although 18.6 % of participants reported that they had experienced a refusal to their request to purchase syringes. Almost all PWID did not dispose of their used syringes safely [45]. Though eight of 16 PDHRS were available for PWID, but only at low level (<20 %), the acceptance rates were high, and PWID were highly supportive of additional PDHRS.

Not surprising, free syringes from pharmacies are not currently offered. The success of NPSS is as part of the pharmacy business. Although NPSS from pharmacies were common, operation hours created a significant barrier against purchasing syringes. Perceived discrimination may also prevent PWID from purchasing syringes from pharmacies [30]. In other studies in Yunnan, PWID reported pretending to buy OTC drugs when purchasing syringes to avoid discrimination [41, 42]. In this study, most PWID wanted to buy syringes from pharmacies where they buy OTC or prescription drugs, but less than half chose pharmacies at the same neighborhood/region where they live. These findings suggest that fears of discrimination and stigma either from pharmacists/pharmacy staff or from others in their neighborhood are potential barriers against obtaining syringes from pharmacies. Prior research has also found that hostile service environments may increase the odds of improper syringe disposal [46].

Free printed materials about HIV, Hepatitis C, and STI risk reduction and free blood pressure checks that are commonly used to promote business ranked the first and second most frequently used PDHRS. The other six PDHRS targeting high risk populations were provided by less than 3 % of pharmacies. Future pharmacy based harm reduction interventions could begin with services that are mutually beneficial to pharmacies and PWID. Naloxone [47] would be an example of such service.

There were eight categories of services not currently offered in pharmacies in Xichang. Lack of “free condoms”, “free syringes”, and “exchanging used syringes for new ones” is probably linked with business concerns of reduced revenue for these services [18, 2931, 3537]. Legal considerations [23] may contribute to the lack of HIV testing [4850], vaccinations for Hepatitis A and B [51], syringe disposal [45], and directly dispensing methadone [47, 52]. The dearth of “a written drug treatment referral” may be due to lack of “time” and professional training for pharmacists [18, 2931, 35, 37]. Financial concerns could be resolved by reimbursements, similar to pharmacy vouchers, for syringes [19]. At the time of investigation, HIV testing was only available in medical facilities [4850] not pharmacies. After approval from China FDA, HIV test kits may become available in pharmacies [48]. Currently, methadone clinics are only government administered [7]. As an alternative, pharmacies in areas with high numbers of PWID could dispense methadone [7, 52, 53], which may make MMT more available and cost-effective than only dispensing at national clinics [7] where discrimination and stigma have been documented [19, 20, 22, 23, 54]. Similarly, used syringes could be disposed at pharmacies [46]. In order to offer greater harm reduction services, pharmacy staff need training to improve their knowledge and skills (including drug treatment referrals) and enhanced sensitivity toward PWID. Due to easy access at community health centers [4951], it is not necessary to provide vaccinations in pharmacies.

The limitations of the current study should be noted. All data was based on self-reports. Snowball sampling was used, and the participants were recruited primarily from harm reduction sites limiting the generalizability of the findings. Future studies should recruit PWID from the general communities. Respondent driven sampling could be applied [55]. Further studies should also examine barriers for pharmacies to provide harm reduction services.

Conclusions

Although community pharmacies have been providing services to PWID in many countries and in parts of China, comprehensive PDHRS had not been reported in Liangshan where HIV is prevalent and the major route of HIV infection is injection drug use. The findings indicated that NPSS from pharmacies provided most PWID with new syringes, but disposal of used syringes was problematic. At the time of investigation, 8 of 16 services were already available. PWID were interested in using all the potential PDHRS, if available. Of the 16 PDHRS, 14 were feasible to be provided if pharmacies benefited financially from providing such services. Future harm risk reduction programs should provide the reimbursements for pharmacies and training for pharmacists.

Declarations

Acknowledgement

We thank Qi Luo, Ting Huang, Shou Liu, Si Qin from WCSPH and Qianping Liu, Zhengqing Jiang from XSDPC for their hard and successful work in data collection. This study was supported by the National Institute on Drug Abuse (NIDA; R21 DA024971; Principal Investigator: Carl Latkin), and has been supported by the Johns Hopkins Center for AIDS Research (1P30AI094189). Yi Yang is supported by China Scholarship Council for her postdoctoral fellow study at JHSPH.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Social Medicine and Health Administration, School of Administration, Chengdu University of Traditional Chinese Medicine
(2)
Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health
(3)
Department of Epidemiology and Biostatistics West China School of Public Health, Sichuan University

References

  1. Ma Y, Li ZZ, Zhang KX. Identification of HIV infection among drug users in China. Zhonghua Liu Xing Bing Xue Za Zhi. 1990;11:184–5 (in Chinese).Google Scholar
  2. China Ministry of Health, UNAIDS, WHO. Estimate for the HIV/AIDS epidemic in china. Beijing: China Ministry of Health; 2011.Google Scholar
  3. Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. The Lancet. 2008;372(9651):1733–45.View ArticleGoogle Scholar
  4. Press Office of Ministry of Health. 2012 China AIDS Response Progress Report Beijing. China: Ministry of Health the People’s Republic China; 2012.Google Scholar
  5. Ruan Y, Qin G, Yin L, Chen K, Qian H-Z, Hao C, et al. Incidence of HIV, hepatitis C and hepatitis B viruses among injection drug users in southwestern China: a 3-year follow-up study. AIDS. 2007;21:S39–46.View ArticlePubMedGoogle Scholar
  6. Ruan Y, Liang S, Zhu J, Li X, Pan SW, Liu Q, et al. Evaluation of harm reduction programs on seroincidence of HIV, hepatitis B and C, and syphilis among intravenous drug users in southwest China. Sexually Transmitted Diseases. 2013;40(4):323–8.View ArticlePubMedGoogle Scholar
  7. Zhou Y-B, Wang Q-X, Liang S, Gong Y-H, Yang M-x, Nie S-J, et al. HIV-, HCV-, and Co-Infections and Associated Risk Factors among Drug Users in Southwestern China: A Township-Level Ecological Study Incorporating Spatial Regression. PloS One. 2014;9(3):e93157.Google Scholar
  8. Mathers BM, Degenhardt L, Ali H, Wiessing L, Hickman M, Mattick RP, et al. HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage. The Lancet. 2010;375(9719):1014–28.View ArticleGoogle Scholar
  9. Zhang L, Li J, Lai W, Feng L, Zeng Y, Liu L, et al. Prevalence and correlates of needle-sharing among new and long-term injection drug users in southwest China. Substance Use & Misuse. 2010;45(14):2503–23.View ArticleGoogle Scholar
  10. United Nations Office on Drugs and Crime, World Drug Report 2014 (United Nations Publication, Sales No. E.14.XI.7)Google Scholar
  11. National bureau of statistics of the people’s republic of China. Total Population (2012 year-end)(10000 persons). http://data.stats.gov.cn/english/easyquery.htm?cn=C01
  12. 2011 Annual bulletin of financial and social development in Liangshan Prefecture. Bureau of Statistics of Liangshan Yi autonomous prefecture, 2012. http://www.lsz.gov.cn/lszrmzf/gmjjhshfztjgb/780375/index.html.
  13. 2011 Annual bulletin of financial and social development in Sichuan Province. Bureau of Statistics of Liangshan Yi autonomous prefecture and Sichuan General Survey Group of National Bureau of Statistics of China, 2012. http://www.sc.stats.gov.cn/sjfb/tjgb/201203/t20120307_2577.html.
  14. Dong C, Huang ZJ, Martin MC, Huang J, Liu H, Deng B, et al. The Impact of Social Factors on Human Immunodeficiency Virus and Hepatitis C Virus Co-Infection in a Minority Region of Si-Chuan. the People’s Republic of China: A Population-Based Survey and Testing Study. PLoS One. 2014 Jul 2;9(7):e101241. doi:10.1371/journal.pone.0101241.
  15. Dai S, Shen Z, Zha Z, Leng R, Qin W, Wang C, et al. Seroprevalence of HIV, syphilis, and hepatitis C virus in the general population of the Liangshan Prefecture, Sichuan Province, China. Journal of Medical Virology. 2012;84(1):1–5.View ArticlePubMedGoogle Scholar
  16. Liu S, Wang QX, Nan L, Wu CL, Wang ZF, Bai ZZ, et al. The changing trends of HIV/AIDS in an ethnic minority region of China: Modeling the epidemic in liangshan prefecture. Sichuan Province Biomedical and Environmental Sciences. 2013;26(7):562–70.PubMedGoogle Scholar
  17. Holtgrave DR, Pinkerton SD, Jones TS, Lurie P, Vlahov D. Cost and cost-effectiveness of increasing access to sterile syringes and needles as an HIV prevention intervention in the United States. JAIDS. 1998;18:S133–8.PubMedGoogle Scholar
  18. Busza J, Douthwaite M, Bani R, Scutelniciuc O, Preda M, Simic D. Injecting behaviour and service use among young injectors in Albania, Moldova, Romania and Serbia. International Journal of Drug Policy. 2013;24(5):423–31.View ArticlePubMedGoogle Scholar
  19. Wilson H, Brener L, Mao L, Treloar C. Perceived discrimination and injecting risk among people who inject drugs attending Needle and Syringe Programmes in Sydney, Australia. Drug and Alcohol Dependence. 2014;144:274.Google Scholar
  20. Rivera AV, DeCuir J, Crawford ND, Amesty S, Lewis CF. Internalized stigma and sterile syringe use among people who inject drugs in New York City, 2010–2012. Drug and Alcohol Dependence. 2014;144:259–64.View ArticlePubMedPubMed CentralGoogle Scholar
  21. Crawford ND, Amesty S, Rivera AV, Harripersaud K, Turner A, Fuller CM. Randomized, community-based pharmacy intervention to expand services beyond sale of sterile syringes to injection drug users in pharmacies in New York City. American Journal of Public Health. 2013;103(9):1579–82.View ArticlePubMedPubMed CentralGoogle Scholar
  22. Lang K, Neil J, Wright J, Dell CA, Berenbaum S, El-Aneed A. Qualitative investigation of barriers to accessing care by people who inject drugs in Saskatoon, Canada: perspectives of service providers. Subst Abuse Treat Prev Policy. 2013;8(35):1–11.Google Scholar
  23. Hammett TM, Phan S, Gaggin J, Case P, Zaller N, Lutnick A, et al. Pharmacies as providers of expanded health services for people who inject drugs: a review of laws, policies, and barriers in six countries. BMC Health Services Research. 2014;14(1):261.View ArticlePubMedPubMed CentralGoogle Scholar
  24. Glanz A, Byrne C, Jackson P. Role of community pharmacies in prevention of AIDS among injecting drug misusers: findings of a survey in England and Wales. BMJ. 1989;299(6707):1076–9.View ArticlePubMedPubMed CentralGoogle Scholar
  25. Sheridan J, Strang J, Taylor C, Barber N. HIV prevention and drug treatment services for drug misusers: a national study of community pharmacists’ attitudes and their involvement in service specific training. Addiction. 1997;92(12):1737–48.View ArticlePubMedGoogle Scholar
  26. Myers T, Cockerill R, Worthington C, Millson M, Rankin J. Community pharmacist perspectives on HIV/AIDS and interventions for injection drug users in Canada. AIDS Care. 1998;10(6):689–700.View ArticlePubMedGoogle Scholar
  27. Matheson C, Bond CM, Mollison J. Attitudinal factors associated with community pharmacists’ involvement in services for drug misusers. Addiction. 1999;94(9):1349–59.View ArticlePubMedGoogle Scholar
  28. Coffin MPO, Linas BP, Factor SH, Vlahov D. New York City pharmacists’ attitudes toward sale of needles/syringes to injection drug users before implementation of law expanding syringe access. Journal of Urban Health. 2000;77(4):781–93.View ArticlePubMedPubMed CentralGoogle Scholar
  29. Koester SK, Lewis BA, Bush TW. Limited access to syringes for injection drug users in pharmacies in Denver, Colorado. Journal of the American Pharmacists Association. 2002;42(6s2):S88–91.Google Scholar
  30. Fuller CM, Galea S, Blaney S, Ompad DC, Deren S, Jarlais DD, et al. Explaining the relationship between race/ethnicity and pharmacy purchased syringes among injection drug users in New York City. Ethnicity and Disease. 2004;14:589–96.PubMedGoogle Scholar
  31. Cooper EN, Dodson C, Stopka TJ, Riley ED, Garfein RS, Bluthenthal RN. Pharmacy participation in non-prescription syringe sales in Los Angeles and San Francisco counties, 2007. Journal of Urban Health. 2010;87(4):543–52.View ArticlePubMedPubMed CentralGoogle Scholar
  32. Mackridge AJ, Scott J. Experiences, attitudes and training needs of pharmacy support staff providing services to drug users in Great Britain: A qualitative study. Journal of Substance Use. 2009;14(6):375–84.View ArticleGoogle Scholar
  33. Rudolph A, Standish K, Amesty S, Crawford N, Stern R, Badillo W, et al. A community based approach to linking injection drug users with needed services through pharmacies: an evaluation of a pilot intervention in New York City. AIDS Education and Prevention. 2010;22(3):238.View ArticlePubMedPubMed CentralGoogle Scholar
  34. Torre C, Lucas R, Barros H. Syringe exchange in community pharmacies—The Portuguese experience. International Journal of Drug Policy. 2010;21(6):514–7.View ArticlePubMedGoogle Scholar
  35. Janulis P. Pharmacy nonprescription syringe distribution and HIV/AIDS: a review. Journal of the American Pharmacists Association. 2011;52(6):787–97.View ArticleGoogle Scholar
  36. Zaller ND, Yokell MA, Apeakorang N, Gaggin J, Case P. Reported experiences during syringe purchases in Providence, Rhode Island: implications for HIV prevention. Journal of Health Care for the Poor and Underserved. 2012;23(3):1310–26.View ArticlePubMedGoogle Scholar
  37. Pollini RA, Gallardo M, Ruiz S, Case P, Zaller N, Lozada R. Over-the-Counter But Out of Reach: A Pharmacy-Based Survey of OTC Syringe Sales in Tijuana, Mexico. Journal of Health Care for the Poor and Underserved. 2014;25(2):637–51.View ArticlePubMedGoogle Scholar
  38. Rose VJ, Lutnick A, Kral AH. Feasibility of Providing Interventions for Injection Drug Users in Pharmacy Settings: A Case Study among San Francisco Pharmacists. Journal of Psychoactive Drugs. 2014;46(3):226–32.View ArticlePubMedPubMed CentralGoogle Scholar
  39. China Food and Drug Administration. Measures for the Administration of Permits for Medical Device Operation Enterprises.2004–2014Google Scholar
  40. Hammett TM, Kling R, Johnston P, Liu W, Ngu D, Friedmann P, et al. Patterns of HIV prevalence and HIV risk behaviors among injection drug users prior to and 24 months following implementation of cross-border HIV prevention interventions in northern Vietnam and southern China. AIDS Education & Prevention. 2006;18(2):97–115.View ArticleGoogle Scholar
  41. Sha L, Li Y-Z. Zhu Y-y: A sampling survey on syringe exchange and methadone maintenance treatment (MMT) among drug abusers in Yunnan province. Chinese Journal of AIDS & STD. 2008;3:015.Google Scholar
  42. Xue H, Liu H. Sun J-p: An analysis of service model and cost of needle and syringe exchange in 19 counties of Yunnan. Chinese Journal of AIDS & STD. 2013;5:011.Google Scholar
  43. Ruan Y, Chen K, Hong K, He Y, Liu S, Zhou F, et al. Community-based survey of HIV transmission modes among intravenous drug users in Sichuan. China Sexually Transmitted Diseases. 2004;31(10):623–7.View ArticlePubMedGoogle Scholar
  44. Yin L, Qin G, Qian H-Z, Zhu Y, Hu W, Zhang L, et al. Continued spread of HIV among injecting drug users in southern Sichuan Province, China. Harm Reduct J. 2007;8(4):6.View ArticleGoogle Scholar
  45. The State Council of China. Management Regulation of the People’s Republic of China on Medical Waste.2003.Google Scholar
  46. Quinn B, Chu D, Wenger L, Bluthenthal RN, Kral AH. Syringe disposal among people who inject drugs in Los Angeles: The role of sterile syringe source. International Journal of Drug Policy. 2014;25(5):905–10.View ArticlePubMedGoogle Scholar
  47. Standing Committee of National Congress of China, The Drug Administration Law of People’s Republic of China.2001.Google Scholar
  48. The state Council of China. Regulation of the People’s Republic of China on HIV/AIDS prevention and control. 2006.Google Scholar
  49. The state Council of China. Regulations of the People’s Republic of China on Medical Institutions Management. 1994.Google Scholar
  50. China Ministry of Health. Regulations of the People’s Republic of China on Medical institutions management. China: implementing rules; 1994.Google Scholar
  51. Regulation of the People’s Republic of China on the Administration of Circulation and Vaccination of Vaccines, (2005).Google Scholar
  52. The state Council of China. Regulation of the People’s Republic of China on Narcotic Drugs and Psychotropic Drugs.2005Google Scholar
  53. Standing Committee of National Congress of China. Law of the People’s Republic of China on Medical Practitioners.1998.Google Scholar
  54. Mateu-Gelabert P, Gwadz MV, Guarino H, Sandoval M, Cleland CM, Jordan A, et al. The staying safe intervention: training people who inject drugs in strategies to avoid injection-related HCV and HIV infection. AIDS Education and Prevention. 2014;26(2):144.View ArticlePubMedPubMed CentralGoogle Scholar
  55. Heckathorn DD. Respondent-driven sampling: a new approach to the study of hidden populations. Social Problems. 1997;44:174–99.View ArticleGoogle Scholar

Copyright

© yang et al. 2015

Advertisement