ASSESSMENT OF HIV, AFB (+) TB CONTRACTION AND EFFICACY OF INTERVENTION MEASURES ON INTRAVENOUS DRUG USERS IN DAKLAK PROVINCE, 2011 2012

1 MINISTRY OF TRAINING AND EDUCATION MINISTRY OF HEALTH NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY - - - - - - - - - * - - - - - - - - - PHAM THO DUOC ASSESSMENT OF HIV, AFB (+) TB CONTRACTION AND EFFICACY OF INTERVENTION MEASURES ON INTRAVENOUS DRUG USERS IN DAKLAK PROVINCE, 2011 - 2012 Major : Public Health Serial No. : 62 72 03 01 SUMMARY OF DOCTORAL THESIS ON PUBLIC HEALTH HA NOI – 2014 2 THE ISSUE IN QUESTION 1. The imperative of thesis HIV/AIDS and TB are and were two troubling public health issues. With two agents, two transmission mechanisms, exposed subjects pose different infected symptoms; however, the conditions of the two health issues go hand in hand. HIV was the main cause of failure in the preventive strategy of TB and vice versa, TB was the main cause of fatalities among HIV infected persons. Scientific evidence had revealed that intravenous drug users (IDUs) had higher risk of HIV infection, implicating opportunistic infections among which was TB. The increase of TB infections might create a boost on increase of HIV/TB coinfection. There had been tremendous researches on the prevalence of HIV infections among IDUs and TB infected group in several areas in the nation. However, in Vietnam, and particularly Daklak Province, there had not been many specific study on HIV infections, AFB (+) TB and HIV/TB coinfection among IDUs, in order to obtain scientific evidence which shall in turn be helpful for planning preventive strategy on IDUs in particular and the community health in general. On that basis, we conducted this study with the following goals: 1. Determining the prevalence of HIV and AFB (+) infections among IDUs in Daklak Province, 2011. 2. Providing descriptions of several related factors of HIV/TB coinfections on study subjects. 3. Determining the efficacy of community intervention measures to prevent HIV and TB infections among IDUs during the period 2011 – 2012. 3 2. Further contributions by thesis This thesis was the first systematic study on the prevalence of HIV, AFB (+) TB and HIV/TB coinfection among IDUs in Daklak. This study provided descriptions on several risk factors which might increase HIV/TB coinfection. The preliminary study roll-out had accurately assessed the efficacy of community intervention measures against HIV, TB infections among IDUs in Daklak Province. 3. Scientific significance and practicality of thesis 3.1. Scientific significance: Thesis adopted the cross-sectional study model of pre- and post- community intervention. Adopted methods on sample collection and data analysis were accurate and creditable. From the collected data and result interpretations, the thesis had determined certain indices of prevalence of HIV, AFB (+) TB, HIV/TB coinfection, HIV/TB coinfection risk factor index and efficacy index of community intervention measures among IDUs on study areas in Daklak Province. 3.2. Practicality of thesis: The study results provided preliminary scientific data which contribute to proposal of intervention measures model, and control of HIV, AFB (+) TB and HIV/TB coinfection among IDUs. The study results provided practical data serving teaching purposes and being the prerequisite for further follow-up studies. 4. Outline of thesis: the body of thesis consisted of 126 pages (excluding appendices, table of contents, glossary) and was divided into: Issues in question (3 pages); Chapter 1 – General (43 pages); Chapter 2 – study subjects and approach (17 4 pages); Chapter 3 – study results (28 pages); Chapter 4 – Discussion (31 pages); Conclusion (2 pages); Recommendation (1 page) and Portfolio of publicized research papers (1 page). Thesis had 45 tables, 07 graphs, 04 maps and 01 figure. The appendices consisted of 120 references (37 in Vietnamese, 83 in English), surveys (commitment on study participation and survey questions); blood collection slip; oral fluid collection slip; CHAPTER 1: GENERAL 1.1. The situation of HIV/TB coinfection 1.1.1. The situation of HIV/TB coinfection on a global scale According to WHO, by the end of 2012, there were approximately 34 million cases of HIV infections globally. Among HIV infected persons, one third of them had high risk of TB infection, therefore, increased the number of TB infected persons. HIV infected persons had 20-30 times risk of contracting active TB in compared with HIV non-infected persons. An estimation of 1.4 million deaths were caused by TB in 2011. 1.1.2. The situation of HIV/TB coinfection in Vietnam and Daklak Province The rate of HIV/TB coinfection had increased drastically, from 0.5% in 1996 to 4.8% in 2004. A study took place in 2005 in 6 provinces had revealed the prevalence of HIV/TB coinfection to be 4.7%. Investigation on mortality rate relating to coinfection in HCMC had revealed that 34.1% TB/HIV patients were deceased before the completion of treatment regimens and the mortality rate among AFB (+) TB patients 5 infected with HIV was 26% in compared with 2% among HIV (-) patients. From the first 5 cases detected of HIV infections in 1993 until the end of December, 2010, Daklak Province had recorded 1,520 cases of HIV infection among which 623 were advanced to AIDS, 351 were deceased because of AIDS; the rate of HIV infection among TB patients was 3.1%. 1.2. Factors relating to HIV/TB coinfection 1.2.1. Socio-economic and living condition factor Factors such as: social integrity, degrading behaviors, ethnic groups, financial problems, poverty, illiteracy, unemployment, domestic violence or sexual discrimination, etc. might affect the risk of HIV/TB coinfection in a community, especially among high risk groups (Intravenous drug users (IDUs), prostitutes, and MSM). 1.2.2. Knowledge and behavior Lack of knowledge, negative behaviors and action against the norm such as drug abusing which might lead to sharing of needles and unsafe sexual intercourse are among factors that affected the increase of HIV infections. HIV infections shall weaken the immune system which implicated opportunistic infections, among which was TB. 2.2.2. Group of intravenous drug users Intravenous drug users were the group of highest risk of HIV infection due to sharing of needles and unsafe sexual intercourse. 2.2.3. Group of female prostitutes Female prostitutes were faced with risk of HIV infections, unstable financial conditions, social discrimination and domestic issues. HIV infection among female prostitutes 6 fluctuated from 0.3% to 23% depending on geography and areas. 2.2.4. Group of men who have sex with men (MSM) Currently, MSM was the main route of HIV transmission in most of countries in Latin American. 3. Several intervention measures on HIV/TB coinfection Programs about sharing needles. Replacement/opposition treatment of opium-like substance; voluntarily HIV consultation and test. ARV treatment and caring for HIV infected persons; Information, education and risk reduce consultation; giving out condoms and control on sexual transmitted diseases. Coordination in HIV and TB surveillance acitivities; HIV/TB supervision and assessment; HIV/TB preventive activities; HIV/AIDS diagnosis and treatment for TB infected persons and coordinated diagnosis, TB treatment for HIV/AIDS patients; Control on TB and HIV infected persons. CHAPTER 2: STUDY METHODS 2.1. Study subjects Study subjects were males of age above 18 who had been an IDUs for at least 6 months and were residences of Daklak Province. Subject must volunteer to participate in study and perform all 3 steps of study: (i) completed the survey without skipping any information; (ii) provided blood sample and (iii) provided 3 samples of oral fluid. 2.2. Date and location of study 2.2.1. Date of study: from January 2011 to December 2012. 2.2.2. Location of study 7 Selected areas were those whose IDUs record showed higher numbers and prevalence of HIV infected persons, which were: Buon Me Thuot City, EaHLeo District and Krong Pac District. 2.3. Design of study Cross-sectional descriptive inquiry Non-testimonial assessment study of community intervention measures 2.4. Sample size and sample collection method Full size sample was selected. Year 2011: 298 IDU subjects were studied pre- intervention. Year 2012: 301 IDU subjects were studied post- intervention. 2.5. Variables and indices: were subjected to study objectives. 2.6. Means of study: participation agreement, survey questionnaire, collection slip and collecting equipment for blood and 03 samples of oral fluid. 2.7. Data collection method Cross-sectional inquiry: phase 1 (July ~ October 2011) and phase 2 (12 months after intervention). Study subjects were interviewed by questionnaire and taken 3ml venous blood and 03 oral fluid sample on 3 different time. Collected samples were preserved and transported as stipulated with biological safety ensured to the laboratory within the same day. 8 2.8. Testing methods HIV tests were conducted at Prevention of HIV center of Daklak and Institute of Hygiene and Epidemiology of Tay Nguyen. Test of AFB in 3 oral fluid samples were conducted in Tuberculosis and Lung disease Hospital of Daklak Province. All tests were completed as stipulated by Ministry of Health. 2.9. Main contents of community intervention measures on HIV prevention Building outreach group approaching community and deploy peer education, reaching to target subjects. Holding media activities: different types of media material, group discussion. Deploying peer education, reaching to target subjects: giving out needles, condoms, and holding infected group clubs. Announcing locations providing medical and social service, health care for subjects. 2.10. Data processing and analysis Data was cleaned before entered and processed in computers by SPSS software for Windows 15.0 and applied the Medical – Biological algorithm to deduce the results by  2 test or OR; if occurrence frequency was less than 5, Fisher test was adopted for calibration. Single variable analysis technique was adopted for assessment and determination of related factors affecting the prevalence of HIV and AFB (+) infections, HIV/TB coinfection. Efficacy of intervention measures was determined according to following formula: 9 EFFICACY INDEX = Post-intervention ratio – pre- intervention ratio x 100 Pre-intervention ratio 2.11. Ethics issue during study Study was approved by Ethics Council of National Institute of Hygiene and Epidemiology. CHAPTER 3: RESULTS OF STUDY 3.1. Prevalence of HIV and AFB (+) TB infection among IDUs in Daklak, 2011 was determined. 3.1.1. Basic information about study subjects Study subjects were 298 IDUs cases, in which there are 131 subjects in Buon Ma Thuot City (43.9%), 100 subjects in EaHleo District (33.6%) and 67 subjects in Krong Pac District (22.5%). The average age is 26.9 years old in which the majority is from 20 to 29 years old (54.4%); The majority graduated middle school (62.1%); single (57.1%); living with family (56.4%); currently employed (87.2%); of E De ethnic group (1%); of Tay Nung ethnic group (6.1%); of Kinh ethnic group (92.9%). Intravenous drug injection behaviors of study subjects. 10 Table 3.1. The prevalence of intravenous drug injection behaviors Intravenous drug injection behaviors n No. of subjects Ratio (%) Age started to use drugs < 20 years of age 257 108 42,0 > 20 years of age 149 58,0 Needle sharing Yes 298 168 56,4 No 130 43,6 Injection frequency ≤ 1 time/day 298 167 56,1 2-3 times/day 71 23,8 ≥ 4 times/day 60 20,1 Type of drug Heroin 298 256 85,6 Others 42 14,4 The results in Table 3.1 showed that the drug using behaviors of study subjects might increase the HIV infection risk. Pre-intervention: the ratio of intravenous drug users under 20 years of age was 42%; sharing needles were 59.7%; injection frequency ≤ 1 time/day, 2-3 times/day and ≥ 4 times/day are in respective order of 56.1%; 23.8%; and 20.1%; majority of addictive drug in use was Heroin which accounted for 85.6%, others 14.4%. [...]... prevalence of HIV infections, AFB (+) TB infections and HIV /TB coinfection Table 3.2 The prevalence of HIV, TB infections and HIV /TB coinfection Category No of subjects Ratio % HIV infection 38 12,8 AFB (+) TB infection 11 3,7 HIV /TB coinfection with AFB (+) 8 2,7 TB infection with AFB (+)/ HIV (-) 3 1,2 In 2011, the current prevalence of HIV (+) infection among IDUs group was 12.8%; prevalence of TB with AFB. .. 15 HIV (+) AFB (+) 12,3% 9,5% 10 5 3,2% 0 Kinh Minority Chart 3.1 Distribution of HIV and AFB (+) TB infection among ethnic groups Result of Chart 3.1 showed the HIV and AFB (+) TB infection pre -intervention distribution in all ethnic groups (Kinh and minority) 3.2 Several factors relating to HIV /TB coinfection 3.2.1 Relation between HIV (+) infection and AFB (+) TB infection 13 Table 3.4 Relation between... persons in HIV and TB prevention work Reinforcing direct media work in order to raise awareness among IDUs regarding the damage of HIV and TB as well as HIV /TB coinfection Expanding and deploying of intervention programs on HIV infection such as giving out clean needles and condoms Expanding medical gridlines and HIV /TB prevention services in rural areas, minority areas Enhancing the connection and. .. HIV infection among IDUs, 2011- 2012 3.3.1 Efficacy on change of prevalence of HIV (+), AFB (+) TB and HIV /TB coinfection post -intervention Table 3.9 showed the comparison of current HIV infection and AFB (+) TB, HIV /TB coinfection among IDUs group Study indices Pre- Post- Ratio % Ratio % Efficacy Index (%) p Current HIV infection 12,8 8,6 32,8 p > 0,05 Current AFB (+) TB 3,7 2,3 37,8 p > 0,05 HIV /TB. .. with AFB (+) was 3.7%; HIV /TB coinfection was 2.75% and TB infection among IDUs had not contracted HIV was 1.2% 3.1.3 Distribution of HIV and AFB (+) TB injection according to locations Table 3.3 Prevalence of HIV and AFB (+) TB infection according to locations Locations Type of No of Ratio % infection subjects Buon Ma HIV (+) 21 16,0 Thuot City AFB (+) 5 3,8 (n=131) HIV /TB (+) 5 3,8 EaHLeo HIV (+) 12... HIV /TB coinfection Risk of HIV /TB coinfection among IDUs group is high in the following groups: Above 20 years of age Sharing of needles Injection frequency higher or equal to 2 times/day 3 Efficacy of community intervention measures on IDUs group The effect of community intervention measures on IDUs group had shown in the change of post -intervention indices (12 months) in compared with pre -intervention: ... HIV infection cases, AFB (+) TB is 3.8%, HIV /TB coinfection is 3.8% EaHLeo District had HIV cases of 12%, AFB (+) TB 3%, HIV /TB coinfection 2%; Krong Pac District had HIV infection case of 7.5%, AFB (+) TB 4.5% and HIV /TB coinfection 1% 4.2 Factors relating to HIV /TB coinfection According to study results, at the pre -intervention stage, HIV (+) among IDUs group was the factor that increased risk of TB. .. rate of needles sharing in the last 01 month had decreased 22 CONCLUSION 1 Current HIV and TB infection through AFB test among IDUs group in Daklak Province, 2011 Prevalence of HIV infection in 2011 was 12.8% Kinh was 12.3% and minority was 19.0% Prevalence of AFB (+) in oral fluid test was 3.7% Kinh was 3.2% and minority was 9.5% Prevalence of HIV /TB coinfection was 2.7% 2 Several factors relating... prevalence of HIV /TB coinfection in Son La Province is 13.4% Distribution of HIV and AFB (+) TB according to locations were an important index as well as the existence, potential of infected 20 factors that could trigger transmission to other subjects In research study, pre -intervention stage detected case of HIV and AFB (+) TB among IDUs as well as HIV /TB coinfection in all 3 regions selected for study Buon... District AFB (+) 3 3,0 (n=100) HIV /TB (+) 2 2,0 Krong Pac HIV (+) 5 7,5 District AFB (+) 3 4,5 (n=67) HIV/lao (+) 1 1,5 12 All three selected locations were detected of HIV (+) and AFB (+) TB, and HIV /TB coinfection In which, Buon Ma Thuot City had high rate; the follow-ups are EaHLeo District and Krong Pac District (Table 3.3) 3.1.4 Distribution of HIV infection and AFB (+) TB infection among to ethnic . MINISTRY OF TRAINING AND EDUCATION MINISTRY OF HEALTH NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY - - - - - - - - - * - - - - - - - - - PHAM THO DUOC ASSESSMENT OF HIV, AFB (+). certain indices of prevalence of HIV, AFB (+) TB, HIV /TB coinfection, HIV /TB coinfection risk factor index and efficacy index of community intervention measures among IDUs on study areas in Daklak. 3.3. Assessment on efficacy of community intervention measures on HIV infection among IDUs, 201 1- 2012. 3.3.1. Efficacy on change of prevalence of HIV (+), AFB (+) TB and HIV /TB coinfection post-intervention