To the Editor:
In his letter, Dr Amon states that our article should clarify the ethical protections and recruitment process of the patients and whether our study conformed to the tenets of the Declaration of Helsinki. We felt that we had nothing to declare as we had stated all the ethical issues clearly in the text.1 Our research is a genetic association study based on case-control approach, and we followed the standard protocol in the field. In our study, intravenous drug users (IDUs) were recruited from communities, including participants in free HIV voluntary counseling and testing, needle and syringe programs, or methadone maintenance treatment programs of 6 districts (Yingjiang, Lincang, Zhaotong, Baoshan, Qujing, and Dehong) with the help of local Centers for Disease Control and Prevention.1 Readers of the Journal may refer to Yin et al2 for the recent development of the national methadone maintenance treatment in China.
In our study, written informed consents and a standard questionnaire about history of intravenous drug usage and other risk factors were obtained from each volunteer before the study. Volunteers could end the interview at any time or refuse to answer any question(s) and decline to donate blood without any negative consequence. After HIV-1 status test, we informed the result of test to each participant in a confidential way regardless of HIV-1 infection. For HIV-1-positive IDUs, we strongly recommended they went to voluntary counseling and testing to further assure their HIV-1-infected status. In summary, we conducted the research following international rules governing sample handling and in accordance with the Helsinki Declaration, and the institutional review board of the Kunming Institute of Zoology approved this study.
Dr Amon claimed that Human Rights Watch conducted a series of investigations about IDUs in China and found that “Chinese IDU are subject to severe human rights abuses from government policies and police practices, in both the community and when detained.” This statement does not represent the true situation and was (inadvertently) biased. There are several problems in their study.3 The most serious limitation is that the sample size in all their investigations was very small and was insufficient to reflect the real situation. For example, only a total 33 drug users were interviewed from sites spreading among 3 prefectures including Beijing, Yunnan, and Guangxi in the study conducted in 2009.3 Apparently, this small sample cannot represent the entire drug user group. In his letter, Dr Amon stated “Other researchers have also reported on the abuse and desperation of drug users in detention centers, including the use of electric shocks while detainees viewed pictures of drug use, and, in 1 study, that 9% of 3213 Chinese heroin users had swallowed glass to get a medical exemption from forced treatment. It is estimated that the centers have a rate of relapse of between 90% and 100%.” Similar statements were also found in Jürgens et al4 article, but Dr Amons statements were different from Jürgens et al's (Note that Dr Amon is one of the co-authors in the Jürgens et al article). In their article, Jürgens et al4 wrote that “investigations have uncovered extreme abuse, such as the administration of electric shocks while viewing pictures of drug use; The rate of relapse is 90%-100%. In 1 study, 9% of 3213 Chinese heroin users had taken extreme steps such as swallowing glass to gain a medical exemption from forced treatment.” Both reported cited figure as extracted from the original data about the electric shocks5 and swallowing glass6 were from 2 studies, which were published in Chinese. These 2 Chinese articles might have been misunderstood by these authors during their citations, possibly due to the language problem. For example, the retrospective study about swallowing foreign bodies was carried out from January 1999 to January 2002 by Su et al6 with objectives to learn more about the reasons and the incidence of swallowing foreign bodies before and during the detoxification and rehabilitation. Su et al6 reported that 272 of 3213 drug users had history of swallowing various foreign bodies, including coins, clips, rings, and pins.6 Only 2 of these 272 clients (0.7%) had incidence of swallowing glass.6 More importantly, 96.7% of the incidences (263 of 272) of swallowing foreign bodies occurred “outside” the detoxification center.6 In Amon's letter, the number of incidence of swallowing glasses was wrongly quoted as 272 and 9% of the total investigated 3213 subjects, whereas the correct figure should be 2 incidences (0.06% of the 3213 subjects).
Through scientific research, many effective prevention and treatment strategies have been identified for treatment of HIV/AIDS patients and drug users. Political officials, policymakers, administrators, service providers, and patients are increasingly working together to achieve these goals. In the article by Wu et al,7 they had clearly presented the overview of the evolution of China's response to HIV/AIDS, in particular about the impressive progress in the development and implementation of effective intervention strategies including the legislation to control HIV/AIDS, implementing interventions to reduce HIV transmission and free antiretroviral therapy. The recent initiation and rapid expansion of the national methadone maintenance treatment program in China have made a considerable impact on drug use and HIV infection among drug users.2 We strongly believe that human rights, ethics, and the protection of intravenous drug users and HIV/AIDS patients are and will continue to be improved in China, especially under these programs which are the results of collaboration between government and NGOs, researchers, service providers, and policymakers.
Feng-Liang Liu, MS*†
Yong-Gang Yao, PhD*
Hong Li, MS‡
Yong-Tang Zheng, PhD*
*Key Laboratory of Animal Models and Human Disease Mechanisms of the Chinese Academy of Sciences & Yunnan Province, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan, China †Graduate School of the Chinese Academy of Sciences, Beijing, China ‡Yunnan Center for Disease Control and Prevention, Kunming, Yunnan, China
1. Liu FL, Qiu YQ, Li H, et al. An HIV-1 resistance polymorphism in TRIM5α gene among Chinese intravenous drug users. J Acquir Immune Defic Syndr
2. Yin W, Hao Y, Sun X, et al. Scaling up the national methadone maintenance treatment program in China: achievements and challenges. Int J Epidemiol
3. Human Rights Watch. Where Darkness Knows No Limits: Incarceration, Ill-Treatment and Forced Labor as Drug Rehabilitation in China
. New York, NY: Human Rights Watch; 2010.
4. Jürgens R, Csete J, Amon JJ, et al. People who use drugs, HIV, and human rights. Lancet
5. Wang ZC. A Study of giving up drug-taking by mean of psychotherapy. Psychol Sci
. 1997;20:161-163 [in Chinese].
6. Su JY, Wen AY, Shen HL. Analysis of 272 cases of swallowing foreign body in compulsory detoxification. Chin J Drug Dependence
. 2004;13:221-223 [in Chinese].
7. Wu Z, Sullivan SG, Wang Y, et al. Evolution of China's response to HIV/AIDS. Lancet