Background: China introduced the Methadone Maintenance Treatment (MMT) to cope with the rapidly rising number of heroin users and related increases in the prevalence of HIV for a decade. Currently, China’s MMT program is the largest single MMT program in the world. However, relatively low retention rate of MMT has been a concern for China’s MMT program ever since the first pilot was initiated. The objectives of the prospective cohort study are: 1) To document the retention rate of MMT program and identify the factors associated with retention of MMT in Yunnan. 2) To examined effect of MMT for 204 drug users who entered methadone maintenance between baseline and 6-month follow-up.
Methods: Anonymous in-depth interviews were conducted with 13 clients of MMT clinics, 18 dropouts from MMT, 8 officers and 19 services providers of MMT program. The perceived facilitators and barrier associated with retention of MMT from the perspectives of clients and service providers were documented. Meanwhile, a prospective cohort study was employed in this study. 523 clients from the four selected MMT clinics from four city/prefectures of Yunnan Province were recruited into the cohort, beginning on January 2014 and followed up until September 2014. In total, 523 clients completed questionnaire interview at baseline and 204 clients who still remained in MMT clinics were interviewed at six-month follow up. Additionally, to evaluate the effects of MMT program, this study also compared the baseline information and followed up information among the 204 clients who were remaining in the MMT program.
Results: The qualitative study revealed that over ten years, MMT program has already gradually accepted by societies including the department of public security. Fear of arresting in and/or around MMT clinics was not a major barrier for accessing and remaining in. Service providers believed they are able to prescribe appropriate dosage of methadone to clients. However, that methadone dose and dose-adjustment are still problem at the maintenance phase because of poor provider-client communication, misunderstanding and inappropriate perceptions of the MMT treatment goals and side effect. The major individual-level barriers are: 1) Lack of knowledge of MMT treatment goal, side effects and long-term treatment process; 2) fear of addiction of methadone and opposition to utilize MMT on a long-term basis; 3) low accessibility of comprehensive services such as psychological counseling and side effect diagnosis and treatment; 4) economic burden; 5) concurrent use of heroin and methadone due to temptation of drug user friends and lack of family support, and 6) the drug-related stigma and discrimination in societies. The major structural and institutional barriers are: 1) high turnover rate and shortage of human resources in MMT clinic due to financial difficulties and lack of institutional support; 2) lack of related skills such as communication and counseling skills because of insufficient professional trainings; 3) logistical barriers such as the inflexible service hours, location and transportation and take away dose of methadone is restricted. 4) MMT services diversity and, 5) affordability of MMT. Furthermore, this study showed that individual barriers and structural barriers often interact synergistically and make the situation more complicated and difficult.
The quantitative study found that the cumulative probabilities of retention at 1, 3 and 6months were 80.9%, 47.8% and 39.0%, respectively. The mean survival time was 3.5 months (Se=0.098) and median was 2.9 months. Seven factors were found to significantly predict retention in the MMT clinics. The seven factors were: female gender, in employment, good family relationships and support, currently married, never dropped out of MMT, subjective feeling of adequate dosage, and good provider-client relationship.
With regarding to the effects of MMT, this study found that those clients who remaining in MMT reduced their heroin using and only 3 clients (1.5%) reported sharing needles in last month at the follow up. The MMT improved the sexual function and the average times of having sex in last month. Meanwhile, the proportion of having commercial (paid) sex also increased. The physical health status of clients retained in the program was improved significantly. However, the psychological health status underwent no considerable improvement through the 6-month MMT.
Conclusions: Individual and institutional interacted each other, which causes relatively low retention rate of Chinas’ MMT program. Currently, the quality of service in MMT is still at the low level. Non-treatment predicting predictors, such as employment status, family relationship and support, provider-client relationship, need to addressed and improved by providing the comprehensive services to clients. Improving the quality of comprehensive services should set up as the first priority of China’s MMT program after ten-year rapid scaling up.