'Social evils' and harm reduction: the evolving policy environment for human immunodeficiency virus prevention among injection drug users in China and Vietnam

Aims This paper reviews the evolution of government policies in China and Vietnam regarding harm reduction interventions for human immunodeficiency virus (HIV) prevention, such as needle/syringe provision and opioid substitution treatment. Methods The work is based upon the authors' experiences in and observations of these policy developments, as well as relevant government policy documents and legislation. Results Both countries are experiencing HIV epidemics driven by injection drug use and have maintained generally severe policies towards injection drug users (IDUs). In recent years, however, they have also officially endorsed harm reduction. We sought to understand how and why this apparently surprising policy evolution took place. Factors associated with growing support for harm reduction were similar but not identical in China and Vietnam. These included the emergence of effective 'champions' for such policies, an ethos of pragmatism and receptivity to evidence, growing collaboration across public health, police and other sectors, the influence of contingent events such as the severe acute respiratory syndrome (SARS) epidemic and pressure from donors and international organizations to adopt best practice in HIV prevention. Conclusions Ongoing challenges and lessons learned include the persistence of tensions between drug control and harm reduction that may have negative effects on programs until a fully harmonized policy environment is established. Excessive reliance on law enforcement and forced detoxification will not solve the problems of substance abuse or of HIV among drug users. Ongoing evaluation of harm reduction programs, as well as increased levels of multi-sectoral training, collaboration and support are also needed.