changes in high risk behavior

AIDS Behav (2006) 10:S47–S56 DOI 10.1007/s10461-006-9138-y ORIGINAL PAPER Changes in High-Risk Behaviors Over Time Among Young Drug Users in South Vietnam: A Three-Province Study Le Thuy Lan Thao Æ Christina P Lindan Æ Deborah B Brickley Æ Le Truong Giang Published online: 20 July 2006 Ó Springer Science+Business Media, Inc 2006 Abstract Vietnam is in the midst of an expanding HIV epidemic, primarily driven by an increase in injection drug use in young people This study was conducted to understand the patterns and initiation of drug use, and the sexual risk behavior among youth in three provinces in southern Vietnam A cross-sectional survey was conducted among male and female drug users under age 25 recruited from drug treatment centers (N = 560) and the community (N = 240) in Ho Chi Minh City, Dong Nai and Ba Ria-Vung Tau The majority of those surveyed (82%) began by smoking heroin; after a year, 57% were injecting heroin and/or opium Initiation of drug use frequently occurred in entertainment venues Among injectors, 23% shared needles; 71% of all users were sexually active of whom 77% had unprotected sex More than half of those recruited from treatment centers had previously been in drug treatment Public health programs to prevent and treat the dual epidemics of HIV and drug abuse must be able to access and respond to the needs of youth, many of whom are unemployed and exposed to drug traffic L T L Thao Æ L T Giang Ho Chi Minh City Provincial AIDS Committee, Ho Chi Minh City, Vietnam C P Lindan Æ D B Brickley (&) Institute for Global Health, University of California, 50 Beale Street, Suite 1200, San Francisco, CA 94105, USA e-mail: dbain@psg.ucsf.edu L T Giang Ho Chi Minh City Health Department, Ho Chi Minh City, Vietnam Keywords IV Drug Users Æ Risk-taking Æ Sexual Behavior Æ Heterosexual Transmission Æ Vietnam Æ Asia Introduction Since the first AIDS case was reported in Ho Chi Minh City (HCMC) in 1990, the HIV epidemic in Vietnam has spread rapidly, primarily due to the expansion of injection drug use throughout the country (Hien, Long, &Huan, 2004) The estimated total number of HIV infections in Vietnam is 263,000 (Ministry of Health Vietnam 2005), 51% of which are attributed to injection drug use (Hien et al., 2004) The greatest number of reported HIV infections occur in the north, where drug use proliferates along trafficking routes and the borders of China and Laos (Beyrer et al., 2000; Hammett et al., 2005) However, all provinces in Vietnam currently report persons with HIV infection and an increase in the number of cases due to sexual transmission The southern city of Ho Chi Minh accounts for a quarter of the total national reported and estimated cases of HIV (UNAIDS and WHO, 2005) In 2004, the HIV prevalence among injection drug users in HCMC was 53% and 16% among female sex workers (Hien et al., 2004) During the past 10–15 years, the epidemiology of drug use in Vietnam has changed, providing new challenges for the control of narcotic use, as well as HIV transmission Prior to 1996, narcotic drug abuse occurred primarily among older men who smoked or injected blackwater opium (Lindan et al., 1997; Reid and Costigan, 2002) By 2002, approximately 80% of registered drug addicts were under age 35 123 S48 (‘‘Vietnam: Country profile’’, 2002) This increase in drug use among youth largely accounts for the dramatic rise in the proportion of reported HIV infections among young people: 16% of all HIV infections in 1995 were among those less than 30 years of age, compared to 69% in 2004 (Hien et al., 2004) Control of HIV infection is linked to control of drug abuse in Vietnam; both are managed within the Committee for AIDS and for Control of Drug Abuse and Prostitution In Ho Chi Minh City, a pilot program was established in which 22 drug treatment centers (also known as rehabilitation centers) housing more than 30,000 drug users provided detoxification, education, vocational training and health care Although there are rehabilitation centers elsewhere in Vietnam, the HCMC program had by far the greatest number Identified drug users remain in treatment for up to and in some cases more than years Approximately twothirds of these clients are now being released as their mandated rehabilitation time has been completed (‘‘3,097 drug addicts in Ho Chi Minh City finish rehab’’, 2005) HCMC is grappling with ways to integrate these young people into society Effective strategies to prevent initiation of drug use among youth need to be developed and evaluated The public health approach to HIV and illicit drug use has been based primarily on using peer outreach to provide education, some needle exchange and counseling (Khoat, West, Valdiserri, & Phan, 2003) Methadone treatment is not yet available, but it is anticipated that it will soon become legal (JVnet, 2005) High unemployment rates, injecting as well as smoking practices, and sexual risk behavior with multiple partners are issues that need to be addressed to successfully prevent HIV infection in this population In order to learn more about patterns of drug use and sexual and injecting behaviors among young drug users, this study was conducted by the HCMC AIDS Committee in three different provinces in the southern region of the country Methods Setting Subjects were recruited from three cities in southern Vietnam, chosen to represent different urban settings: a metropolis, a suburb, and a smaller resort town Ho Chi Minh City is the largest city in Vietnam, with a population of million and the commercial and industrial center of the country Dong Nai is a rapidly 123 AIDS Behav (2006) 10:S47–S56 developing industrial zone in the suburbs of HCMC Ba Ria-Vung Tau is a beach resort about 120 km from HCMC that attracts both domestic and foreign tourists Study Subjects Subjects were recruited both from drug rehabilitation centers and community venues A sample size of 400 participants from HCMC, and 200 from each of the two other cities was based on feasibility and cost It was planned that approximately 75% of subjects would be recruited from drug rehabilitation centers and 25% from the community, based on the belief that the majority of identified drug users would be in treatment In addition, the feasibility of recruitment from drug rehabilitation centers was expected to be easier In HCMC, where large numbers of drug users in both the community and rehabilitation centers could easily be identified, this sampling approach was taken In the other two locations, however, the total number of drug users was much smaller, and the ability to recruit subjects was limited by the size of the rehabilitation centers and/or the availability of identified users in the community Thus, 88% of study participants from Dong Nai and 43% from Ba Ria-Vung Tau were recruited from treatment centers At the time of the study, there were eight government rehabilitation centers in HCMC, and participants were recruited from each, proportional to the percentage of total drug admissions received by that site For example, a total of 300 subjects were to be recruited from rehabilitation centers in HCMC, and 100 from the community If center A received 20% of all drug rehabilitation admissions in the city, then 20% of the 300 subjects were enrolled from that site Both Dong-Nai and Vung-Tau had only one drug center each, and all eligible residents at the time of the study were asked to participate Recruitment was conducted by experienced social workers and counselors who were employed and trained by the HCMC AIDS Committee In the drug treatment centers, health and social workers who were familiar with young drug users conducted the interviews Recruitment and interviewing of community based drug users were carried out by peer educators currently working in those communities All study personnel had experience in counseling drug users; they also received additional training in interviewing and in research methods as part of this study Recruitment occurred from October 1999 to March 2000 AIDS Behav (2006) 10:S47–S56 Subjects were self-identified users of opiate drugs and < 25 years in age Because all users in treatment could not be enrolled, participants were selected by systematic sampling Counselors described the study protocol and procedures and received verbal consent from the subjects Participation was voluntary and study staff made clear that refusal to participate would not influence ability to receive treatment or services Subjects received a small gift (value less than US$1) to compensate for their participation All questionnaires were anonymous and no identifying information was collected; names of the subjects were not recorded or linked with the survey in any way S49 using v2-test for differences in categories, or student’s t-test for differences in mean values Data are presented stratified by recruitment site (drug rehabilitation centers versus the community) Ethical Review The study was reviewed and approved by the Provincial AIDS Committee of Ho Chi Minh City before an Institutional Review Board (IRB) was established An IRB and NIH Federal Wide Assurance are currently in place The Committee on Human Research at UCSF provided approval for UCSF co-authors to participate in data analysis and manuscript writing Measures Questionnaire items and methods of approaching drug users were explored during focus group discussions with peer educators The questionnaire was administered by trained study staff in Vietnamese using lay language and common terms Areas addressed included basic demographic characteristics of respondents, drug use behaviors (both at the beginning of drug use and currently), sexual behavior, condom use, and knowledge and attitudes related to HIV There were four questions about HIV transmission regarding whether HIV could be transmitted from mother to child, by sharing needles or injection equipment, through sex, or via mosquitoes or insects There were three questions asking whether it is possible to prevent HIV transmission by using condoms during sex, using clean needles/injection equipment, and by not touching or eating with persons who have AIDS There were five additional questions regarding the utility of condoms Discriminatory attitudes towards persons with HIV/AIDS (PLWHA) were identified by asking five questions: whether PLWHA should be fired from jobs and isolated; whether their identity should be provided to the public; whether they should be allowed to work and live as usual; whether their identity should be hidden to avoid discrimination; and whether their health and psychological well-being should be supported Analysis Data were entered onsite into EpiInfo and analyzed using Intercooled Stata 7.0 Distribution of responses were evaluated using proportions, mean and median values Data was initially stratified by city, gender, recruitment venue (community or treatment center), age, employment status, and financial status to identify relationships of interest Differences were evaluated Results Demographics Table shows the demographic profile of subjects by type of recruitment site (community versus treatment center), which varied by city Approximately 19% of participants were women The median age was 20 (range 13–24), and 19 subjects were between 13 and 15 years of age The majority had only elementary or primary education, and 5% were illiterate Of those older than 18 years, only 34% had achieved a high school education (data not shown) About one-half were employed, 17% were students, and the remainder had no job Three quarters of all subjects described their families as poor or struggling with just enough to live on The vast majority (87%) of subjects lived with their families and 65% were completely financially dependent upon them; 55% reported that their family was a main source of drug money Of the 560 recruited from treatment sites, 37% had entered voluntarily, 20% had been sent there by their families, and 43% had been arrested and were undergoing mandatory treatment There were some notable differences between those interviewed from the community compared to treatment centers Those in treatment tended to be younger (less than 22 years old) and to have higher levels of education and be students They were more likely to be financially dependent on families, and those families were better off financially—only 6% were described as poor compared to 21% of families of community participants In addition, a greater proportion in treatment (62% vs 40%) relied on the family as the source of drug money Across provinces, subjects recruited from the treatment centers were similar demographically, whereas there were some differences among those recruited 123 S50 AIDS Behav (2006) 10:S47–S56 Table Demographic characteristics of 800 young drug users by recruitment site Recruitment site Total All City*** Ho Chi Minh City Dong Nai Ba Ria-Vung Tau Gender, male Age, years*** 13–15 16–18 19–21 22–24 Educational level*** Illiterate Primary/elementary Some high school or more Employment*** Job Student Unemployed Ever married Living with family*** Financially dependent on family*** Completely Partially Independent Family economic status*** Poor Enough to live on Wealthy/middle class Sources of drug moneya Work Loans Family Other Reason for being in treatment Voluntary Government mandated Request of family Community Treatment centers N % N % N % 800 100 240 30 560 70 400 200 200 650 50 25 25 81 100 25 115 195 25 13 58 81 300 175 85 455 75 88 43 81 19 177 312 292 22 40 37 14 43 80 103 18 33 43 134 232 189 24 41 34 39 503 258 63 32 22 174 44 73 18 17 329 214 59 38 372 133 295 91 699 47 17 37 11 87 115 21 104 33 184 48 43 14 77 257 112 191 58 515 46 20 34 10 92 519 149 132 65 19 17 123 52 65 51 22 27 396 97 67 71 17 12 85 519 196 11 65 25 51 143 46 21 60 19 34 376 150 67 27 319 46 443 80 40 55 10 126 97 35 53 40 15 193 40 346 45 34 62 – – – – – – 208 238 114 37 43 20 – – – – – – P-values refer to differences between recruitment sites across categories, using v2 statistics ***P < = 001 a Categories are not mutually exclusive from communities (data not shown) Unemployment was higher among participants from Vung Tau compared to the other two cities (56% vs 36% in Ho Chi Minh City and 31% in Dong Nai, P < 0.001); those recruited from Ho Chi Minh City were more likely to be financially independent from their families (39% vs 22% in Vung Tau, and 4% in Dong Nai, P < 001) Men and women in the study were similar in age, education and employment status; however, more women lived on their own without financial support (data not shown) They were more likely to be married (19% vs 10% of men, P < 01), live apart from their families (22% vs 11% of men, P < 01) and be 123 financially independent of them (24% vs 15% of men, P < 01) The economic status of their families was also lower—82% of women were from poor or financially struggling families compared to 74% of the families of men surveyed (P < 05) Drug Use Behaviors Table highlights the drug use patterns of subjects recruited from rehabilitation centers and the community The mean length of time using drugs was 2.7 years (median years, range 1–12 years); those in treatment had been using for slightly longer—about half had AIDS Behav (2006) 10:S47–S56 S51 Table Drug use patterns among 800 young drug users by type of recruitment site Community All Current Age 13–18 (N = 196) ** Used drugs £2 years Used drugs >2 years Current age 19–24 (N = 604)* Used drugs £2 years Used drugs >2 years Current methods of drug usea Injection Smoking Snorting/swallowing Currently share injection equipment Drugs used currentlya Heroin Opium Non opiates or marijuana Reason for initiating drug use Peer pressure Personal problems Family problems Other Used drugs with whom initially*** No one/alone Friends Other people Previously been in treatment*** Treatment centers N % N % 240 30 560 70 42 15 74 26 72 67 52 48 98 85 54 46 187 234 44 56 147 91 18 35/126 61 38 28 306 257 31 57/274 55 46 21 170 77 12 71 32 550 15 98 187 22 15 16 78 444 39 37 40 79 7 14 220 76 92 32 91 449 20 293 16 80 52 P-values refer to differences between recruitment sites across categories, using v2 statistics *P < = 05 **P < = 01 ***P < = 001 a Not mutually exclusive categories been using drugs for more than years, and some up to 12 years Nearly all those in treatment were using heroin and only 1% used opium, whereas 32% of those from the community were using opium There were some differences in sharing practices by city of recruitment (data not shown): 24% of injectors in HCMC reported sharing, compared to 22% in Vung Tau and 19% in Dong Nai Almost 80% stated that peer pressure was their main reason for using drugs initially, and most began using with friends Many, 52% of those recruited from treatment centers and 32% of those in the community, had previously been in treatment, and roughly similar proportions believed they could eventually give up drugs (65% of those in treatment vs 37% from the community) Only 11 participants reported selling drugs (data not shown) At initiation of drug use, the majority (87%) of subjects smoked and only 9% injected (Table 3) This changed significantly over time—when surveyed, the majority of users (57%) reported injection practices Among those who had switched method of use, the mean time to change was 14.1 months Sharing needles or drug paraphernalia was reported by only onequarter of injectors, and was the same at drug initiation (26%) and at the time of the survey (23%) Heroin was by far the most commonly used substance; at drug initiation, 94% used heroin: 88% exclusively and 6% mixed it with other drugs; only 2% were using opium and 8% marijuana By the time of the study, 90% overall were using heroin, and the proportion of opium users had increased slightly (10%) In general, those using heroing continued to so—only 7% of heroin users switched to opium, whereas among those using opium initially, 67% continued to so Among marijuana users, 83% were smoking or injecting heroin when surveyed (data not shown) Overall, 17% had changed their primary drug since initiation Frequency of drug use increased from a mean of 1.6 to 2.5 times per day More than half the survey participants (53%) began using drugs at an entertainment place such as a cafe´, restaurant or karaoke bar There was a general trend from initially smoking heroin at entertainment venues, to injecting heroin at home or with friends Even so, a 123 S52 AIDS Behav (2006) 10:S47–S56 Table Change in drug use: at drug initiation and currently, among 800 young drug users At drug initiation Method of usea Smoking Injecting Snorting/swallowing Changed method of use since initiation No months to change, mean (SD) Share injection equipment Drug used and methoda Heroin, Smokeb Inject Snort/Swallow Opium, Smokeb Inject Marijuana Medication Changed drugs used since initiation No times/day use drugs £1 2–3 ‡4 Primary location of usea Shooting gallery Own house Entertainment placec Friend’s house Other Purchase drugs wherea Shooting gallery Entertainment place Friend Other Currently N % N % 696 74 101 – – 19/72 87 13 – – 26 348 453 51 403 14.1 92/400 44 57 50 SD 10.6 23 750 659 62 98 13 67 20 – 94 82 12 1 – 720 339 376 50 83 82 27 37 135 90 42 47 10 10 17 399 360 31 50 46 158 499 143 20 62 18 87 133 425 160 45 11 17 53 20 133 262 269 156 46 10 33 34 20 – – – – – – – – 552 36 148 72 69 19 a More than one response possible b Proportion smoking, injecting etc are calculated using the entire cohort (800) as the denominator c Entertainment places include restaurants, cafes, karaoke bars, etc significant proportion (28% of injectors, 40% of smokers, and 35% of heroin users) continued to use drugs at entertainment sites (Table 4) Opium was used most commonly at shooting galleries (54%) All drugs, including opiates, marijuana and other drugs were purchased primarily at shooting galleries Sexual Risk Behaviors Table describes the sexual behaviors of study subjects Most, but not all, were sexually experienced: 82% of women, 71% of men, and 67% of those who had never been married Among the 586 who had had sex, 20% had sex with friends in their drug-using group, 37% with friends outside of their using group, and 24% with casual partners About twice as many women 123 (41%) as men (20%) reported sex with casual partners We did not ask women whether they had engaged in commercial sex, although 32% of men had visited female sex workers About half of respondents reported never using condoms, and this was not significantly different between men and women Condom use with spouses was low—6% reported always using them Among those who were married and had other relationships, 32% never used condoms with extramarital partners (data not shown) Knowledge and Attitudes about HIV/AIDS Participants in the study were generally knowledgeable about HIV/AIDS (Table 6) Most (86%) could correctly answer all questions about HIV transmission, AIDS Behav (2006) 10:S47–S56 S53 Table Current primary location of drug use and purchase among those who used heroin and/or opium (N = 800) Method of intake and drug used Primary location of drug use Shooting gallery Entertainment placea Friend’s house Own house N % N % N % N % Method Injectors N = 453 Smokers N = 348 Drug Heroin N = 720 Opium N = 83 96 37 21 11 130 144 29 41 86 65 19 19 154 112 34 32 85 50 12 60 256 13 36 16 144 13 20 16 250 12 35 15 Current drug used Primary place of purchase Shooting gallery Drug Heroin N = 720 Opium N = 83 a Entertainment placea Friend Other N % N % N % N % 478 77 66 93 34 146 20 71 10 Entertainment places include restaurants, cafes, karaoke bars, et al and 80% could correctly answer all questions about means of preventing HIV However, only 43% of injectors and 21% of non-injectors believed they were at risk for HIV Most had favorable attitudes about how society should respond to people living with HIV/ AIDS Eighty-four percent believed the identity of those with HIV infection should not be disclosed in order to avoid discrimination, and an equal number believed that people living with HIV should be allowed to work and live as usual Almost all (97%) believed that family and health services should provide care and support for people living with HIV Those in treatment were more than twice as likely to have undergone HIV testing than participants from the community (67% vs 28%) A very small number of those who reported having been HIV tested (440), indicated that they were HIV infected (8%), and was higher (12%) among injectors compared to non-injectors (1%) Discussion This study provides important information about how youth in southern Vietnam begin using drugs and how this changes over time Heroin was by far the drug of choice, and opium use was comparatively uncommon Table Marital status and sexual risk behaviors of 800 young drug users All Total Sexually experienceda Sex with whom?a,b Female sex worker Friend in drug using group Other friend Casual partner If married, sex with non-marital partner Frequency of condom usec (N = 532) Always Sometimes Never a Women Men N % N % N % 800 586 100 73 150 123 19 82 650 463 81 71 147 117 217 143 37/91 25 20 37 24 41 – 32 34 51 13/28 – 26 27 41 46 147 85 183 92 24/63 32 18 40 20 38 122 125 285 23 23 54 22 29 57 20 27 53 100 96 228 24 23 54 Includes sexually active single persons, as well as those who were married, divorced, or separated b Categories are not mutually exclusive c Condom use among 108 women and 424 men who were single and sexually active, or married with non-marital partners 123 S54 AIDS Behav (2006) 10:S47–S56 Table Knowledge and attitudes about HIV (N = 800 drug users) HIV transmission knowledgea All questions correct Knowledge about HIV preventiona All questions correct No discriminatory attitudes towards PLWHAa None 2–5 Perceive oneself at risk for HIV Non-injectors (N = 345) Injectors (N = 455) Previously tested for HIV Recruited from community (N = 240) Recruited from treatment centers (N = 560) a N % 685 86 637 80 543 95 162 68 12 20 73 194 21 43 67 373 28 67 Items are described in the Methods section of the text This is in contrast to a decade ago, when opium use was more prevalent, particularly in the southern part of the country One study from the mid-1990s reported that 96% of drug users in treatment were using opium (Tran, Williams, Truong, & Do, 1998) Most young people in our study reported smoking drugs initially, with one-half transitioning to injection within a year This quick transition to injection likely results from increasing addiction, the need for more drug per dose, and the fact that injection is comparatively cheaper Other studies of drug users have found that transition to injection occurred within months to 1.85 years (Hien et al., 2004; Nguyen, Hoang, Pham, & Detels, 2001) Needle sharing in our study was reported by only one-quarter of those injecting drugs, and is considerably less than in other surveys in which up to 70% of injectors in urban settings reported sharing equipment (Hien et al., 2001; Nguyen et al., 2001; Tran et al., 1998) Other reasons for varying rates of sharing may be related to cost, availability of clean needles and concerns about arrest if caught with injection equipment Until now, a policy of sending drug users to large treatment centers for up to years of detoxification and ‘‘rehabilitation’’ has been widely pursued (Rekart, 2002; Vu, 2001) Vast resources have been dedicated to expanding existing drug treatment centers and building new ones At the time of this study there were such sites in HCMC; by 2005, there were 22, mostly run by the government with a few private clinics, and housing 30,000 users Previous data show that upon leaving a rehabilitation center, at least 90% of clients begin using again (International Narcotics Control Strategy Report, 1999) This is consistent with reports of prior treatment among participants in our study—55% of those in treatment and one-third of those in the 123 community had previously been in rehabilitation Because the maximum 2-year detention has now expired for many with mandatory sentences, large numbers of drug users are being released into the community, up to 16,000 in 2006 in HCMC alone (‘‘3,097 drug addicts in Ho Chi Minh City finish rehab’’, 2005) This poses a large challenge in finding ways to support abstinence, education, and reintegration into society A step-down program of 1–3 years in which former drug users can be employed and live in more controlled settings is being pursued With the large efflux of drug users from treatment, information about initiation of drug use will be important for prevention programs and outreach We found that drug use was most often initiated at entertainment venues, such as karaoke bars or cafes, and occurred under peer pressure Even over time, both purchase and use of drugs continued to occur in these public venues, although most drugs were obtained at shooting galleries even if they weren’t used there Developing peer outreach at these sites may be very important in preventing recidivism as well as reducing experimentation with highly addictive drugs We were somewhat surprised to find many young drug users were fairly well-educated, middle class and typically living with and/or receiving financial support from their families This was particularly true of drug users in treatment, who in many cases were sent to treatment by family members Many families were also a source of money for buying drugs This may occur because relatives would rather provide funds than have children steal and bring shame to the family Because of this involvement, an important role may exist for families in supporting prevention, harm reduction and drug abstinence However, this also poses a dilemma for families, many of whom are reluctant to have former drug users return home following rehabilitation Despite concerns about the use of rehabilitation centers, the HIV prevalence rates in HCMC declined significantly in the several years during which the majority of drug users were in treatment Data from HCMC sentinel surveillance show that HIV prevalence among drug users dropped from 83% to 48% from 2002 to 2005, concomitant with reductions in HIV among other at-risk populations As the majority of HIV infected persons were in rehabilitation centers, HIV transmission both sexually and parenterally was reduced In addition, the presence of drug mafia and dealers declined Unfortunately, as former drug users re-enter society, HCMC may witness a return of a ready drug supply as well as the emergence of methamphetamine use AIDS Behav (2006) 10:S47–S56 We did not perform HIV testing and counseling as part of this study By self-report, only 55% of participants claimed to have undergone HIV testing The greater proportion in treatment who had been tested may be a result of national HIV sentinel surveillance which is performed primarily in rehabilitation centers A very small number, only 8% of the sample, admitted to being HIV seropositive This likely reflects underreporting and fear of disclosure due to stigma Sentinel surveillance data among injection drug users indicates that 65% of surveyed injection drug users in HCMC and 20% in Dong Nai were HIV infected during the period when this study was performed (Hien et al., 2004) Even though half of those recruited in our study were injecting drugs, high HIV prevalence rates among non-injecting heroin users have been noted in many reports In a study of 500 drug users in Hai Phong, HIV prevalence among non-injectors was 46% (Nguyen et al., 2001) In HCMC, 25% of surveyed heroin smokers were HIV infected in 2000 (unpublished surveillance data, HCMC AIDS Committee) The reasons for high rates among non-injectors may be due to sexual transmission and the overlap among drug users, their sexual partners, and female sex workers (National AIDS Committee Bureau of Vietnam, 2001) Overall, one-half of those who were sexually active in our study never used condoms with their partners, and one-third of men had visited female sex workers Although we didn’t ask women whether they sold sex, a large proportion, 41%, admitted to having casual sex partners It is possible that many of these women were trading sex for drugs or money The HIV prevalence among sex workers has risen steadily in Vietnam, particularly in the southern part of the country Concomitantly, drug use among female sex workers is a growing problem Studies of sex workers in HCMC and in Hanoi have indicated that 25–45% of them inject drugs, and among them HIV rates are close to 50% (Bain et al., 2003; Tran, Detels, Long, & Lan, 2005) Thus, HIV among female sex workers may be due to injecting drug use and sexual transmission from drug using sex partners It is not clear whether many women identified as sex workers and detained in rehabilitation centers, are primarily addicted to drugs and compelled to sell sex to support a habit; or whether they are female sex workers who have become addicted to drugs This distinction may only be relevant in pointing out that women who sell sex may be in need of harm reduction programs There were several limitations to this study Use of peer educators as interviewers may have biased S55 responses of participants toward socially desirable answers, particularly from among those who were in treatment However, all efforts were made to maintain confidentiality and encourage clients to respond accurately The representativeness of the communitybased sample may be reduced because participants were recruited from among networks of drug users already known to peer outreach workers Likewise, participants enrolled from rehabilitation centers may not be representative of drug users in general We not have information about whether risk behavior, related to drugs or sexual relationships, was taking place during rehabilitation Because males and females are separated and centers are inpatient facilities, it is assumed that drug use and heterosexual sex are infrequent; however, to our knowledge this has not been formally evaluated Questionnaire items were not designed to identify specific recall periods, and we have assumed that ‘‘current’’ drug use refers to the period prior to entry in rehabilitation centers In addition, recall periods were not specified for questions relating to sexual activity and condom use This study and many others point to the need to address the growing population of young drug users in Vietnam who are fueling and most likely to succumb to the HIV epidemic (Giang, Luyen, Thao, & Narimani, 1999; Hien et al., 2004) Many of those in our study were less than 18 years of age, and some had started using drugs by the time they were 13 Innovative prevention programs need to be developed, such as conducting outreach at entertainment sites where young people smoke and exchange drugs Recent evidence shows that community-based interventions for drug users are effective in reducing risk behaviors, yet there remains a gap in the number who could benefit from such interventions and those who actually receive them (Needle et al., 2005) Young users are sexually active and not use condoms regularly This puts them at additional risk of HIV acquisition, and requires that interventions also promote fewer episodes of unprotected sex (Des Jarlais & Semaan, 2005; Go, Quan, Yoytek, Celentano, & Nam, 2006; Nguyen et al., 2001) The recent official recognition of needle exchange and drug substitution as valid components of harm reduction and its inclusion into law will be a big step in moving Vietnam’s HIV prevention programs forward (JVnet, 2006) However, this will only be successful if drug users can obtain clean paraphernalia without fearing arrest, and if methadone becomes available to those who need it Until then, high rates of drug use could spell disaster for many of Vietnam’s youth 123 S56 References 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