Side-effects, such as constipation and dry mouth, are also of concern. Overall, about 75.2% of patients experienced at least once treatment side-effects in the first three months, but t[r]
(1)Effectiveness evaluation of the pilot program
for treatment of opioid dependence with methadone
in Hai phong and Ho Chi Minh cities (After 12 month treatment)
Component II
(2)(3)Organizational Involvements
Ministry of Health (MOH)
Nguyen Thanh Long Nguyen Thi Huynh Pham Duc Manh Nguyen Minh Tam Phan Thu Huong Nguyen Dac Vinh Vu Duc Long Nguyen Quynh Mai Luong Ngoc Khue Tran Quang Trung Nguyen Van Thanh Pham Thi Van Hanh Nguyen Minh Tuan Ngo Thanh Hoi
Hai Phong Provicial AIDS Center
Vu Van Cong
Ho Chi Minh City Provincial AIDS Committee
Le Truong Giang
FHI 360
Stephen J Mills
Tran Vu Hoang (now is with Partners in Health Research) Elizabeth “Betsy” Costenbader
Mark A Weaver Nguyen To Nhu
Pham Huy Minh (now is with USAID) Tran Thi Thanh Ha
Nguyen Cuong Quoc Nguyen Ha Hue Chi
Mai Doan Anh Thi (now is with HAIVN) Kevin Mulvey (now is with SAMSHA)
The United States Agency for International Development
Michael Casssell John Eyers
(4)5 I Introduction
6 II Objectives
7 III Materials and Methods
7 8 9 11 11 11 11
1 Study design Study sites Study population
4 Sample size and sampling methods Key indicators
6 Data collection 6.1 Sources of data 6.2 Data collection
7 Management and analysis of data 7.1 Data management
7.2 Data analysis Ethics
12 IV Results
12 13 13 15 15 18 19 20 21 21 22 23 25 26 29 31 33
1 Participant flow
2 Baseline characteristics
2.1 Demographic and socio-economic characteristics 2.2 Criminal behavior
2.3 Drug use and sexual behaviors 2.4 Health status at baseline 2.5 Quality of life
2.6 Access to medical and social support services Change over time after one year follow up
3.1 Participant drop-out 3.2 Treatment retention
3.3 Treatment process (average dosage, changes in dosage and treatment compliance)
3.4 Treatment side-effects
3.5 Changes in high risk behaviors relating to drug use and unsafe sex 3.6 Physical health, mental health, and quality of life
3.7 Social status, and employment status, and crime 3.8 Access to medical services and social support
34 V Limitations of the study
34 VI Conclusions and recommendations
(5)I Introduction
The Joint United Nations Program on HIV/AIDS (UNAIDS) has estimated that about 33 million people were living with HIV and approximately million people died of HIV-related causes worldwide in 2007[1] Global HIV epidemics vary significantly from region to region in both scale and scope While risky sexual behavior remains the epidemic’s driving force in Africa, drug use behavior is the major factor in Asia This trend remains valid for Vietnam, where injecting drug users account for approximately 45% of the total 190,000 HIV cases in the country [2-4]
According to the HIV/AIDS Estimate and Projection Report in Vietnam 2007-2012, HIV prevalence is concentrated among high risk populations, including injecting drug users (IDUs), female sex workers (FSWs) and men who have sex with men (MSM) [5] Of them, IDUs have been the population most severely affected by HIV Ministry of Publish Security estimated that there were about 170,000 known IDUs in Vietnam in the end of 2008 [2], of whom 30% were living with HIV or potentiallyinfected with HIV
Sharing of syringes and injection equipments is a well-known route of HIV infection and has been shown to be the primary determinant of HIV spread among injectors in Vietnam Additionally, IDUs are also involved in high-risk sexual behaviors, especially with non-injecting partners, making them a potential bridge to transmit HIV to other low risk populations
Since the mid-1990s, Vietnam has implemented various prevention on programs to diminish HIV transmission among established IDUs and its spread to non-injecting populations These included peer education, community outreach, IEC and needle and syringe exchange In 2006, the Vietnam Administration of HIV/AIDS Control (VAAC), Ministry of Health (MoH) started to develop a pilot program on opiate substitution treatment using methadone Methadone, a synthetic opioid, is the most widely used pharmacologic treatment for opioid dependence When intergrated with counselling and supporting services, the methadone maintenance treatment (MMT) has been associated with reduced rates of illicit drug use, needle sharing and lower HIV incidence
Previous studies showed that the proportions of frequent drug use and sharing needles were significantly lower in treated group than untreated after to 18 month follow up [6-16] A study conducted by Moss and colleagues reported the reduction of illicit drug use from 33% to 15% and the decreasing of drug injection from 19% to 6% after year MMT [17]
Metzger DS and et al conducted a similar study, on HIV-negative IDUs in a methadone program and those not in the program Results showed that after 18 months, HIV was 3.5% among the group on methadone and 22% among the group not on methadone [6] And in Hong Kong, where methadone treatment is widely accessible, low HIV prevalence was detected among of methadone maintenance therapy clients 0.3% [18]
Methadone substitution also helps reduce needle sharing and improves the treatment adherence for patients on anti-retroviral therapy (ART) and improve their overall quality of life [6, 7, 15, 16, 19-25]
(6)to reduce the transmission of diseases from this population to other populations; to improve the health status and quality of life; and to increase community reintegration The program adheres to the Ministry of Health’s Guidelines on Methadone Substitution Therapy for the Treatment of Opium Substance Dependence [26, 27]
Methadone is just becoming available in Vietnam and there is limited information on program effectiveness and impediment This evaluation examines what is working and what isn’t working from the perspective of managers and health workers It will also look at awareness and attitudes among clients and their families regarding the quality of services and the acceptance in the community
This is a cohort descriptive study on patients before methadone treatment and after three months, six, nine months and twelve months of methadone treatment It consisted of three components:
Component 1: Evaluation of the MMT pilot program with regard to the infrastructure, human resources, operations and service quality,
Component 2: Initial evaluation of the effectiveness and impact of the program on the health system and society, physical and mental health, drug use status, HIV related risk behavior, illegal activities and quality of life of patients on MMT
Component 3: Cost analysis i.e estimating the cost for establishing and operating a MMT clinic including fixed costs, operating costs, management and administration costs This is the foundation for program scale-up in other cities and provinces
The component is designed to measure and monitor changes over time in physical health mental health status, drug use, HIV risk behaviors, and violations of laws, in participating patients’ quality of life
II Objectives
The objective of the evaluation is to monitor the outcomes of methadone maintenance treatment overtime by looking at:
Changes in drug use status, including needle sharing behavior
Changes in sexual behaviors, including type of partners and condom use
Criminal behaviors
Patients’ physical health
Patient’s mental health
(7)III Materials and Methods 1 Study design
The component is a descriptive, prospective cohort study, following 965 patients receiving treatment at six methadone clinics in Hai Phong and HCMC for 12 months Data for the study were collected from four sources:
Information on patient’s behaviors was collected through personal interviews before treatment, at three months, six months, nine months and 12 months
Information on methadone treatment process was extracted from medical records every three months This includes therapeutic doses and changes in dosing during treatment, clinical features, and withdrawal symptoms
Kessler score on depression and treatment side-effects were extracted from counseling records
Patients’ drug use and blood –borne diseases (HIV, Hepatitis B and Hepatitis C) were monitored through urine test and blood tests
2 Study sites
Hai Phong
Hai Phong is a port city of about 1,800,000 people on the Red River Delta in northern Vietnam HIV/AIDS began spreading in the mid-1990s, mostly among IDUs By the late 1990s, about 60 % of IDUS in Hai Phong were HIV-positive but by 2006 that figure had started to drop [28] and hovers at 40-50% now
Statistics from the Hai Phong Department of Labor, Invalids, and Social Affairs (DOLISA) show that in 2007 there were 9,500 drug users in Hai Phong, 75 % of whom injected Persistent risk factors for IDUs include frequent injection and needle sharing [4, 28] which is also common among commercial sex workers , which increases their risk of HIV beyond that already posed by unprotected sex
Since the onset of the pandemic, government and NGO stakeholders have conducted interventions in prevention, care, and treatment in Hai Phong From the late 1990s there have been numerous community and peer outreach programs Care and treatment, including ART, began in the mid-1990s and currently about 2,000 PLHIV are receiving anti-retroviral
In 2007, the government selected Hai Phong for the methadone pilot, to be carried out at clinics in Le Chan District, Ngo Quyen District, and Thuy Nguyen District Le Chan and Thuy Nguyen MMT came online in April 2008 and Ngo Quyen followed that August
Ho Chi Minh City
Ho Chi Minh City, or HCMC, is Vietnam’s commercial and population center, with over 8,000,000 residents The 2004 figures put the opiate-using population at about 45,000 and 99% of them are heroin users, mainly by injection Most of them had started using heroin in youth and most in the late 1990s [28, 29]
(8)began to drop However, by 2004, new IDUs had driven the numbers back up to 65% As with Hai Phong, government and NGO stakeholders did launch intervention programs, including harm reduction, counseling, and support for prevention and treatment of addiction, and HIV/AIDS care and treatment An MMT pilot program was also initiated in District 4, District 6, and Binh Thanh District in May 2008
3 Study population
Participation in this study is completely voluntary All individuals selected for the MMT program, but not started treatment yet, between January 2009 and October 2009 were eligible for this study, except in the following cases:
Not willing to participate (no signature)
Not in good health conditions
4 Sample size and sampling methods
This study followed 965 patients at six clinics In Hai Phong, out of the total of 477 patients monitored, 10 refused to join the study And in HCMC, of 502 patients invited, only four refused
Table Sample size by location of study
In Hai Phong Sample size In HCMC Sample size
Le Chan 126 District 167
Ngo Quyen 128 District 181
Thuy Nguyen 213 Binh Thanh 150
Total 467 Total 498
For case selection, the Provincial HIV/AIDS Committee (PAC) first provided a list of eligible individuals and then project officers explained the study to them and screening them in the first day they come to the clinics Officers then sought client consent and officially enrolled them
5 Key indicators
The key indicators of the cohort evaluation include:
A description of patient’s characteristics at baseline, including demographic, socio-economic characteristics, previous experiences with substance abuse treatment, and indicators monitored overtime
A description of changes overtime of importance concern, as follows: • Treatment retention
• Methadone dosage, treatment adherence and side-effects • Illicit drug use evaluated by both urine tests and self-reporting • Biological indicators including HIV, Hepatitis B, and Hepatitis C • Injecting and sexual behaviors
• Physical health and mental health • Quality of life
(9)• Employment status
• Usage of supportive services
6 Data collection
6.1 Sources of data
The study team collected data through personal interviews with clients at different times according to study design They also reviewed patient records and counseling records, and took blood or urine samples (See Table 2)
6.2 Data collection
Data collection process began in January 2009 and all collected data was entered in Microsoft Access Patients were interviewed prior to treatment using structured questionnaires, which were developed based on standard tools of measurement, translated and tested before instigation started These questionnaires addressed social factors, marital status, level of education, addiction history, injecting behaviors, sexual behaviors, health status, and incidence of crime (See Table 2) Questions on marital status, work history, incidence of crime, sexual behaviors, and opiate abuse were then asked again after three, six, nine and twelve months of MMT
Table Indicators and data source (through interviews, records review, and testing) Before treatment After 3, 6, and 12 months Interview Medical records/ counseling
templates Interview
Patient records /counseling
templates Behavioral indicators
Evaluating risk behaviors related to the transmission of HIV, HBV, HCV, and STDs
Drug use behaviors
Health indicators
Physical health: clinical and
para-clinical indicators
Mental health: Kessler scale or
minimum mental test
History of opiate addiction,
pre-vious cessation measures
Actual drug use: withdrawal, neurological toxicity, related physical disorders
Other co-morbidities: HIV, Hepa-titis B and C, TB, and other acute or chronic conditions
Progression of treatment: therapeutic dosages, side
(10)Social indicators
Social characteristics: education,
marital status, job, income
Incidence of crime in the home
and in public
Quality of life
Biological indicators Rate of infection with HIV,
Hepatitis B and C * *
Positive urine tests and other tests used to determine drug
use ** **
* Test before treatment and after six months
** Urine test before treatment, after three, six, and nine months
Drug use status is evaluated by urine testing During treatment, series of urine tests are conducted by the clinic, depending on the physician’s decision Five urine tests at baseline, month, month, month and 12 month are performed as requested by research team Illicit opioid drug use is determined by combining routine urine test results from the MMT clinic staff in the month before interview with the urine test results from the research team at the time of interview Patients are considered “using drug” if any of above urine tests was positive Drug use status was defined as yes or no
Patient’s quality of life is evaluated using WHOQOL-BREF questionnaires [31] This consisted of seven questions on physical health, six on mental wellbeing, three on social impact of client’s drug use, and eight on the client’s “environment”
All personal interviews were made by trained research staffs at sites that were confidential and private All data was encrypted by research code and no personal information appeared on any materials Staff extracted indicators on methadone dosage, changes in therapeutic doses, clinical syndromes, and para-clinical testing outcomes from medical records and indicators on side effects, depression using Kessler scales from patient counseling document
The methadone dose would be changed when the patient drops out in a period of more than five days [26, 27], all treatment termination sessions are noted (under three days, 3-4 days and more than days), but only details for dose re-starting are noted for those whose interruption is in three days or more
(11)7 Management and analysis of data
7.1 Data management
Data was reviewed by an independent team and any gaps brought to the attention of investigators Twenty percent of all figures were re-entered (double data entry) and compared with the original data set to reveal any errors
All data sets, from before treatment and again at three, six, nine and twelve months) were independently managed by their teams and grouped into: interviews, patient records, counseling papers, and test results Dossiers on each study participant were kept on file at the testing site and consent papers were filed separately Blood samples were stored at local centers preventive medicine or PAC
7.2 Data analysis
7.2.1 Descriptive analysis
Descriptive analysis including mean, medium and standard deviation will be calculated for continuous measurements and frequency and proportion for categorical variables At baseline, patient’s characteristics are compared across treatment sites, Ho Chi Minh City and Hai Phong using t-test for continuous variables and Chi-square test for categorical variables Wilcoxon test or Fisher Exact test is applied alternatively if the normal distribution of continuous variables or large-sample Chi-square test assumption for categorical variables is violated
7.2.2 Survival analysis
The survival analysis examines the treatment retention during one year of follow-up Treatment retention is defined as time in treatment for up to 12 months The PYR is calculated to the date of lost to follow-up, or death if event dates are available If the date is unknown, the patient is assumed to be at risk for half of that follow-up period The participants are considered as LTFU if they quitted the program Patients, who were missing at any interview round but resumed treatment before months, are considered as missing for the follow-up question but not LTFU
The analysis of treatment retention was conducted using unadjusted survival analysis In fact, we used the Kaplan-Meier curve to characterize the overall treatment retention, and separated curves for those with or without ARV treatment
7.2.3 Changes over time
Changes over time of interested indicators are described using figures For simplicity, statistical tests for change over time are not included
8 Ethics
An FHI internal evaluation committee and the Ethics Committee at the Hanoi School of Public Health reviewed the study proposal, the consent process at each location, educational materials, and recruitment of participants Participants were provided with a copy of their consent form and verbal presentation of this form was accepted in the presence of witnesses in cases where participants could not rsead the document
(12)Collection and management of data, administrative templates, urine samples, blood samples, and other materials were identified by code only and all databases were encrypted coded Templates, lists, tracking books, and other lists connected to participant codes were filed separately and always locked in a place where only authorized personnel could access them
IV Results
The results of the study are presented in three sections: Section describes participant flow; Section presents baseline characteristics; and Section shows treatment retention and changes over time for selected characteristics
1 Participant flow
Figure 1: Progress at one year
977 patients approached
Baseline 965 available
3 Months 930 Available
6 Months 898 Available
9 Months 871 Available
12 Months 852 Available
11 decline interview died
20 arrested died hospitalized moved out
2 voluntary drop-outs lost follow up
3 refused interview
17 arrested died hospitalized moved out
4 voluntary drop-outs returns after missing at lost follow up
2 refused interview
13 arrested lost follow up 10 refused interview voluntary drop-outs returns after missing at and
4 returns after missing at died
1 moved out suicide
7 arrested voluntary drop-out 11 lost follow up moved out
6 returns after missing at hospitalized
(13)We attempted to include all 977 patients, who initiated methadone maintenance treatment in six clinics in Hai Phong and HCMC from January 2009 Eleven patients declined to participate in the study and one patient died during baseline interview due to heart attack The follow-up cohort includes 965 eligible patients
Over the period of 12 months, 113 patients were lost to follow-up, of them patients died The reasons for death and drop out will be described in details in section The final datasets include 965 patients at baseline, 930 patients at months, 898 patients at months, 871 patients at months and 852 patients at one year
2 Baseline characteristics
2.1 Demographic and socio-economic characteristics
The median age for the study population was 30 years (range, 16.6 to 58), the majority were males (95%) HCMC participants differed from Hai Phong participants in a number of ways They were younger (29.3 v 33.8 years old), had significantly higher proportion of female (8% v 1.9%), and higher proportion of single (61% v 43.5%) HCMC had significantly lower proportion of patients who were older than 30 years of age (37.4% comparing to 68%)
Regarding the living arrangements, most patients were living with their parents or siblings at the time of beginning treatment (84.3%), 36.8% living with wife and kids, and less than 10% staying with relatives or friends Nearly 7% respondents stated that they shared house with drug users Most patients had low educational level, with about 56% had only secondary education or lower and less than 5% finished some colleges or university No substantial difference was detected in education across enrollment groups Only half of study subjects (48.3%) completed some vocational training and it becomes clear during the course of the study that jobs creation for MMT patients will continue to be a challenge
On average, patients resided in their treatment location for about 28 years (median 30 years) This stability will facilitate the treatment process, which requires patients to come to clinics daily In Hai Phong, 66.6% of study participants had either full-time or part-time jobs, compared to 61.7% in HCMC Over 27% were day laborers performing basic tasks and only 11.3 % were steadily employed at the time of the study, usually for the family business
Table 3: Demographic and social characteristics of study participants at baseline Hai Phong
(n= 467) (n=498)HCMC (n= 965)Total
Gender n(%)
Male 458 (98.07) 458 (91.97) 916 (94.92)
Female (1.93) 40 (8.03) 49 (5.08)
Age
Mean (year) 33.77 29.27 31.43
(14)Age groups n (%)
Under 20 (1.74) (1.01) 13 (1.36)
20 to 25 46 (10.00) 78 (15.69) 124 (12.96)
25 to 29 93 (20.22) 228 (45.88) 321 (33.54)
30 or more 313 (68.04) 186 (37.42) 499 (52.14)
Marital status n (%)
Single (never married) 203 (43.47) 304 (61.04) 507 (52.54)
Currently married 195 (41.76) 113 (22.69) 308 (31.92)
Living with partners (0.43) 38 (7.63) 40 (4.15)
Separated/divorced/widowed 67 (14.35) 43 (8.63) 110 (11.40)
Education (%)
No schooling 2(0.43) (0.8) (0.62)
Primary 41 (8.80) 53 (10.64) 94 (9.75)
Secondary 206 (44.21) 233 (46.79) 439 (45.54)
Tertiary 197 (42.27) 189 (37.95) 386 (40.04)
University/ colleges 20 (4.29) 19 (3.82) 39 (4.05)
Vocational training n(%) 220 (47.11) 246 (49.50) 466 (48.34)
Employed n (%) 311 (66.6) 307 (61.65) 618 (64.04)
Has income n (%) 456 (97.85) 391 (78.51) 847 (87.86)
Average monthly income (millions VND) 6.13 7.80 6.90
Approximately 98% of study participants in Hai Phong and 79% in HCMC had their own income The average monthly income was about VND 6.9 million ($365) However, that income came from various sources, not all stable Although more than 55% of participants had income from stable sources (either from full-time or part-time jobs), that ‘job-based’ income was just VND 3.36 million per month ($180) Majority of patients received substantial amount of financial support from family (74.4%), with average of VND 5.11 million per month ($268) Only 7.4 % of all study patients revealed that they had incomes from “other sources”, about VND 5.75 million per month on average ($302) Thirty-two patients reported regular income from gambling, theft or drug selling but this number could be underestimated since IDUs have intention to hide their income from illegal sources
Figure 2: Participant sources and levels of income
Work 55.44
74.4
7.36 Family, Partners Others 100%
80% 60% 40% 20% 0%
7
(15)Finally, all participants said that they used their income to buy drugs at an average of VND 6.6 million per month ($349) (against total average income of $365 per month) Only few reported that their expenses were for personal needs or family supports (1.3% and 2.4%)
2.2 Criminal behavior
Nearly 41 % of participants stated that they had been involved in crime (apart from illegal drug use) during their lifetime to support drug use Common behaviors included small-scale theft (13.2%), robbery (10.2%), and assault (18%) Among all participants, 13% were arrested and charged, 20.6% accounted convictions during their life-time
Figure 3: Participants reporting involvement in crime at some point, history of crime
40.83
13.06
20.62 100%
80% 60% 40% 20% 0%
Self-reported criminal activities Arrests/Charges Convictions
However, the figure for those involved in crime during the month before entering the program was less than 5%, possibly due to the patient screening process, which prohibits crime as a condition of acceptance
Figure 4: Behaviors of drug users that had a negative impact on families 100%
90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Sold their own Pawn their own Ever
74.07 75.93
42.38
36.51 38.45 8.39 7.05
14.09 24.35
19.69
Last 30 days
Money theft Sold their home appliance
Pawn their family own
The financial needs to buy drugs had pushed drug users to engage in various activities that negatively affected themselves and their families These included sold or pawn their own properties (74.1% and 75.9%), sold or pawn their family’s properties (36.5% and 38.5%), and cash theft (42.4%) 2.3 Drug use and sexual behaviors
(16)By far, the most frequently used illicit drug during life-time was heroin, with 99.7% of study patients reporting use during their lifetime Opium, cannabis, ecstasy were the next three most common, which were used by 10.7%, 8.4%, and 6.4% of surveyed participants The remaining drugs were used by fewer than 5%
Figure 5: Proportions of participants reporting life-time drug use
99.7 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Others
Sleeping aids Dorlagan Tai ma Cannabis Ecstasy Opium Heroin
6.1 2.4 1.8
3.0 8.4 6.4
10.7
The past 30 day drug use estimates shows the dominance of heroin among all kind of narcotics About 99.5% have used heroin during the 30 days before treatment No patients reported using amphetamines, methamphetamine, tai ma nor benzodiazepam The other drugs were uncommon, which were used by less than 1% of survey participants In the past 30 days, a combination of two drugs was used by 29 patients, while patients told us that they had used different drugs in the past 30 days
Table 4: Drug use behavior in the past 30 days Hai Phong
(n= 467) (n= 498)HCMC (n= 965)Total Frequency of heroin use n(%)
Once per day (1.08) 12 (2.41) 17 (1.77)
2 to times/day 291 (62.85) 316 (63.58) 607 (63.23)
4 times or more per day 167 (36.07) 169 (34) 336 (35)
Methods of drug administered in the past 30 days n (%)
Injecting 379 (81.16) 433 (86.95) 812 (84.15)
Inhaling/ Sniffing/ Ingesting 104 (22.27) 99 (19.88) 203 (21.04)
(17)Table 5: Previous attempts to quit drugs Hai Phong
(n= 467) (n= 498)HCMC (n= 965)Total Had attempted cessation at least once n (%) 451 (96.57) 494 (99.20) 945 (97.93)
Average number of attempts (mean) 6.19 6.64 6.43
Attempted cessation at “06” centers n (%) 70 (15.52) 227 (45.95) 297 (31.43) Reasons for cessation n (%) (self reported)
Friend suggested 223 (49.45) 290 (58.82) 513 (54.34)
Cravings 324 (71.84) 329 (66.73) 653 (69.17)
Depression, boredom 198 (43.90) 224 (45.44) 422 (44.70)
Others 12(2.66) 15 (3.04) 27(2.86)
Time of relapse
Longest (years) 1.08 2.89 2.02
Shortest (years) 0.19 0.39 0.29
Before joining the methadone program, about 98% participants surveyed in the two cities had tried to stop using drugs at least once and average number of attempts was six These rates and duration of cessation are relevant to MMT selection criteria The rate of patients spending any cessation in “06” centers (which take a more penal, forced approach to drug treatment) in HCMC was much higher than that for Hai Phong (46 % vs 15.5%) and this difference may be due to the difference in selection criteria between the two cities On average, duration of successful cessation (totally free from drugs) was two years and the shortest period was more than two months Drug free duration was longer among HCMC participants than Hai Phong As reported, the main reasons for relapse were drug craving (69.2%) and friend suggestion (54.3%)
Figure 6: Proportions of patients reporting needle sharing before treatment
Hai Phong HCMC Total
11.18
0.65
30.32
3.61
21.08
2.19 35%
30% 25% 20% 15% 10% 5% 0%
During life-time In the past 30 days
More than 20% IDUs surveyed did say that they had ever shared needles and syringes with injecting partners when injecting drugs and this was higher in HCMC than in Hai Phong (30.3% vs 11.2%) However, many other studies have also shown that needle sharing in Hai Phong is higher (from 40 to 50%) [3, 4, 28] although this could be due to self-reporting error
(18)While condom use with sex workers was fairly high, at more than 90%, condom use with regular partners was low (36.6%) and here it is worthy of note that the HIV rate among these individuals remains high
Table 6: Sexual behaviors, in % of respondents Hai Phong
(n= 467) (n= 498)HCMC (n= 965)Total
Had engaged in sex 455(97.43) 482 (96.79) 937 (97.10)
Engaged in sex in the past three months 229 (49.04) 222 (44.58) 451(46.74) Average number of partners in the past three
months (among those who had had sex) 1.17 1.19 1.18
Had sex with regular partners 218 (46.68) 216 (43.37) 434 (44.97) Had sex with sex workers or male clients 17 (3.64) 13 (2.61) 30 (3.11) Rate of consistent condom use when having sex
with regular sex partner (n=434) 79 (36.24) 80 (37.04) 159 (36.64) Rate of consistent condom use when having sex
with commercial sex worker (n=29) 16 (94.12) 11 (91.67) 27 (93.10) Regular sex partner was an IDU (among those who
had regular sexual partners, n=434) 35 (16.06) 72 (33.33) 107 (24.65) 2.4 Health status at baseline
At baseline, 12.1% of patients enrolled in the MMT program had chronic medical problems, and 40.2% of them were currently taking prescribed medication on a regular basis Chronic medical problems were more likely common among HCMC patients than those in Hai Phong (18.1% v 5.8%) The average weight of study population was about 55kg Majority of patients weighted from 50-59kg (56.5%) and only few had weight of less than 40kg (~1%) 16.8% of them had experienced heroin shock due to overdose
The prevalence of HIV, Hepatitis B and Hepatitis C among MMT patients was at a very high level and differed by enrollment location Patients enrolled in HCMC program were found to have higher HIV prevalence (42% v 26.9%), higher Hepatitis B (20.6% v.11.5%) and more Hepatitis C (69.7% v 40.8%) This figure slightly contradicts with the results reported in IBBS 2006 This is possibly due to the fact that those enrolled in the pilot MMT program may not representative of the general IDUs population because the strict selection criteria scanned eligible patients to ensure treatment commitment
Figure 7: Prevalence of HIV, Hepatitis B, and Hepatitis C before treatmen
Hai Phong 26.93
11.48
40.84 41.97 20.61
69.7
33.54 16.24
55.91 Hepatitis C
HCMC Total
80% 70% 60% 50% 40% 30% 20% 10% 0%
(19)Table Physical and mental health indicators prior to treatment, from medical records Hai Phong
(n= 467) (n= 498)HCMC (n= 965)Total
Mental illnesses (n, %) (0.22) 1(0.20) (0.21)
Kessler scores on depression
Mean 18.92 22.52 20.76
Median 19 22 20
• ≤ 15 125 (27.17) 74 (15.29) 199 (21.08)
• 16 to 29 315 (68.48) 289 (59.71) 604 (63.98)
• ≥ 30 20 (4.35) 121 (25.0) 141 (14.94)
Average weight (kg) 55.94 53.84 54.86
History of overdose (n,%) 61 (13.06) 101 (20.28) 162 (16.79)
Number of overdoses (times) 1.87 1.84 1.85
One figure of note, approximately 17% of participants has overdosed at least once and on average this occurred twice
2.5 Quality of life
The study team used the 26-question WHO standard measurement tool to determine general quality of life: physical health, mental health, social aspects and environmental aspects
Table Quality of life prior to treatment Hai Phong
(n= 467) (n= 498)HCMC (n= 965)Total General evaluation of quality of life (n,%)
• Very bad (0.64) 11 (2.21) 14 (1.45)
• Bad 40 (8.57) 65 (13.05) 105 (10.88)
• Average 339 (72.59) 354 (71.08) 693 (71.81)
• Good 82 (17.56) 63 (12.65) 145 (15.03)
• Very good (0.64) (1.00) (0.83)
Participant’s satisfaction with their own health (n,%)
• Very unsatisfactory (0.64) (0.31)
• Unsatisfactory 54 (11.56) 121 (24.3) 175 (18.13)
• Average 256 (54.82) 227 (45.58) 483 (50.05)
• Satisfactory 152 (32.55) 134 (26.91) 286(29.64)
• Very satisfactory (1.07) 13 (2.61) 18 (1.87)
(20)Further analysis on the four categories of quality of life shows the significant difference between patients across enrollment location There was a significant difference between the quality of life for patients prior to treatment in Hai Phong and HCMC as well Average scores for physical health were 72.1 in Hai Phong and 64.2 in HCMC and average scores for mental health were 58.3 in Hai Phong and 54 in HCMC However, participants in HCMC tended to give higher scores on social and environmental factors
Figure 8: Quality of life in four health categories 100%
80% 60% 40% 20% 0%
68.0 71.4
56.1 58.3
Mean Median
53.0 50.0 58.9 59.4
Physical health Mental health Society Environment Figure 9: Patient’s quality of life prior to treatment in Hai Phong and HCMC
75 70 65 60 55 50
Hai Phong
Physical health Mental health Society Environment Hai
Phong PhongHai PhongHai
HCMC HCMC HCMC HCMC
2.6 Access to medical and social support services
(21)Figure 10: Participant access to and use of prevention, care, and support services prior to treatment.
74.9 64.5 35.3 12.8 23.2 27.8 4.1 3.1 16.7 3.3 17.3 4.2 22.3 8.2 25.2 7.5 80% 70% 60% 50% 40% 30% 20% 10% 0%
Introduced to services Services used
HCT ARV
treatment
Opportunistics infecti on TX TB treatment
Support for recovering addicted
Peer
education Free N&S
Free condoms
HCT was the most heavily used service among study population Seventy-five % of patients at six clinics were introduced to the HCT and 65% used it in the month prior to treatment About thirteen % was receiving ARV when they entered the MMT program Just over 8% received clean needles and syringes and 7.5% received free condoms And although about 17% of participants were introduced to RDU support services when they enrolled (including cessation counseling, job counseling, social re-integration support), usage in the month prior to treatment remained at only 3.3%
3 Change over time after one year follow up
3.1 Participant drop-outs
After one year of follow-up, 113 patients left the MMT program The cumulative drop-out rates were 3.63% at three months, 7.05% at six months, 9.84% at nine months and 11.71% after one year It is likely that dropout rates in HCMC were higher than that in Hai Phong
Figure 11: Participants drop-out rates over time (cumulative rates)
3 months 5.02 3.63 2.14 9.84 6.94 3.85 12.85 9.74 6.42 14.86 11.71 8.35
6 months months Hai Phong 12 months 20% 15% 10% 5% 0% Total HCMC
(22)Figure 12: Reasons for participant dropout Refused interview
8%
Lost to follow-up
28% Arrested 49%
Had other medical problem
4% Moved
4% Died
7%
3.2 Treatment retention
All patients were followed for 12 month period, adding to a total of approximately 910 PYR Retention in methadone maintenance program has been considered as a measure of program effectiveness Methadone patients, who drop out of the treatment, are more likely to relapse to using drug During the 12 month follow-up period, total 113 patients dropped out of the study Of which, 39 were from Hai Phong, and 74 were from HCMC Figure 12 shows the Kaplan-Meier curve for the treatment retention As can be seen from the curve, the retention rates were approximately 96.37% at months, 93.06% at months, 90.26% at months and 88.29% at 12 months The treatment retention rate is much higher than other methadone maintenance programs conducted in other countries
Figure 13: Kaplan-Meier curve for treatment retention 100%
90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
0
Time in treatment (months)
Treatment Retention Probability
9 12
(23)The treatment retentions for these two groups were almost similar from the beginning to 12 months after commencing treatment At 12 months, retention proportions were 88.6% for ARV patients and 89.5% for non-ARV patients The hazard ratio is 1.08 The log rank test shows that there was no significant difference between these two groups
Figure 14: Kaplan-Meier curve for the treatment retention, by ARV treatment 100%
90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
0
Time in treatment (months)
Treatment Retention Probability
9 12
ARV
3.3 Treatment process (average dosage, changes in dosage and treatment compliance) According to the Ministry of Health guidelines, MMT patients typically begin treatment at 20 mg methadone However, the study team found that more than 54% of patients in Hai Phong and 31.5% in HCMC started at 25mg or higher Then, after three months of treatment, the average dosage was 101 mg After months it was 104 mg and remained almost the same to the end of 12 months Adjustments to dosage typically occurred during the first three months and on average each patient’s dose increased by 100 mg overall according to the standard methadone dosage regimen On average, participants on ARV treatment tended to have much higher doses than those not on ARV After three months, participants on ARV were already at 141 mg and those not on ARV were at 90.8 mg By one year, that figures had changed to 162.1mg and 84.3 mg This also suggested a higher rate of dosage increase
Table Methadone dosage over time
Hai Phong HCMC Total
Starting methadone doses n(%)
• 10 mg 4(0.86) (0.42)
• 15 mg (1.5) 22 (4.44) 29 (3.01)
• 20 mg 200 (42.83) 318 (64.11) 518 (53.79)
• 22 mg (0.21) (0.1)
• 25 mg 140 (29.98) 128 (25.81) 268 (27.83)
(24)Began at average starting dosage (mg) 23.89 21.63 22.73
Average dose after months 96.20 105.50 100.97
• For patients on ARV 136.36 142.80 140.95
• For patients not on ARV 90.86 90.80 90.83
Average dose after months 99.17 109.39 104.36
• For patients on ARV 167.41 149.68 154.70
• For patients not on ARV 89.18 91.26 90.10
Average dose after months 95.40 112.13 103.72
• For patients on ARV 165.29 156.88 159.23
• For patients not on ARV 84.90 88.58 86.47
Average dose after 12 months 95.08 113.67 104.32
• For patients on ARV 175.59 157.08 162.07
• For patients not on ARV 87.18 82.21 84.27
However, at 12 month 20% of patients still needed an increase and 23.5% needed a decrease in methadone dosage All patients, meanwhile, required a dosage increase during the first three months but that figure dropped to 30% after six month, 19.5% after nine months and remained at 20.4% after one year The need for dosage decreases tended to remain constantly around 23-27% from 4th month to 12th month
Figure 15: Changes in methadone dosage during treatment
Month Month Month Months 4-6 Months 7-9 Months 10-12 100.0
12.6
69.9
Dose increase Dose decrease
29.9 34.7
23.5 29.6 25.4 19.526.6 20.4 23.5 100%
80% 60% 40% 20% 0%
The main reasons for dosage increases were withdrawal symptoms and the continuation of drug use In the first months, among all patients whose methadone dosage changed, over 99% of them need dosage increases due to withdrawal symptoms This proportion dropped to 91.6% at months and remained constant till the end of months, but went back to 95.4% after one year The percentage of patients required dosage increase due to drug use reduced steadily, from 94.7% during the first months, to 40.7% at months and 19.7% at months However, during the period from to 12 months, this figure raised up to 37%
However, the rate of patients requiring a dose increases due to starting ARV or TB treatment increased over time: 9% in the first months, to 21% after months, 22.5% after months and 23.4% after one year As the ARV and TB treatment protocol changed, methadone dose adjustment had been applied to many HIV- positive patients This requires the strong cooperation between HIV clinics and MMT sites in the future
(25)Figure 16: Treatment non-compliance over time 1-4 day dose drop-out From or more day dose drop-out
3 months months months 12 months 12.3 2.29 19.5 20.79 0.9 23.44 1.65 2.17 25% 20% 15% 10% 5% 0%
Overall, just over 12.3 % of MMT clients dropped out from to days (no need to re-start dosing or re-start dosing at a dose of half of the current dose) during the first three months This rate increased to 19.5 % over the next months and 23.4% from nine to twelve months Dropout at five days or more, which requires dose re-start, decreased from 2.29% to 0.9 % by the end of the ninth month, but increased up to 1.65% at twelve months
3.4 Treatment side-effects
Side-effects, such as constipation and dry mouth, are also of concern Overall, about 75.2% of patients experienced at least once treatment side-effects in the first three months, but that proportion dropped to around 60.6% by the end of months Increased sweating and urine retention were also common, but these did all reduce over time
Figure 17: Incidence of any side-effects over time
3 months months months 12 months 75.21 68.61 67.31 60.61 80% 70% 60% 50% 40% 30% 20% 10% 0%
Figure 18: Some common side-effects over time
57.16 31.32 25.29 18.68 11.21 43.03 41.31 27.5 17.65 12.74 10.81 26.49 13.94 10.89 70% 60% 50% 40% 30% 20% 10% 0%
3 months months months 12 months 11.08 14.27 25.47 37.15 Sexual problems Increased sweating
Constipation Dry mouth
(26)3.5 Changes in high risk behaviors relating to drug use and unsafe sex
Drug using among methadone patients is determined through three sources of data: 1) Urine tests indicated by clinic’s doctors 2) Urine tests taken at the date of interview after three months, six months, nine and twelve months of treatment and 3) through patient interviews
According to the urine tests conducted by clinics, the rate of MMT patients still using drugs had reduced steady during the first months, from 100% at baseline to 60.2% after month and then dropped to nearly 22% after months The figure then remained at 17 % after three months, and fluctuated between 13% -17% from three to six months From to 12 months, the rate reduced to approximately 10-12% And these findings are results of observations carried out independently by the study team
Figure 19: Proportions of patients with at least one urine test positive over time, clinic based testing
Clinic based testing
Baseline 10 11 12
100
60.19
21.99 17.2 13.39 16.57 14.52 12.09 12.6 10.48 11.3 12 10.66 120%
100% 80% 60% 40% 20% 0%
The more strict definition of drug use status combines clinic based tests and tests recommended by research team Patients are considered as using drug if any of following tests positive:
Urine tests conducted by clinic during month before interview
Urine tests requested by research group at the time of interview Figure 20: Proportions of patient using drug over time
Combined clinic urine tests and recommended by reseach group 100
27.52 19.29 18.56
19.98 120%
100% 80% 60% 40% 20% 0%
(27)Figure 21: Comparison of positive urine tests for ARV clients and non-ARV clients, clinic based testing.
Non-ARV patients ARV patients 100
40.53
24.12 17.77 17.44 18.23 25.13 22.12 25.11 100%
80% 60% 40% 20% 0%
Baseline months months months 12 months
ARV patients tended to use drugs more than those who were not on ARVs Despite dosage increases and higher therapeutic doses, the drug use rates among ARV patients always remained higher, thus indicating a need to revise guidelines
Figure 22: Comparisons between self-reported drug use and combined testing results Self reported drug use Combined testing results
27.52
18.28 19.29
9.8 10.22
19.98 11.5 30%
25% 20% 15% 10% 5% 0%
3rd month 6th month 9th month 12th month 18.56
Comparison between self-reported drug use in the past 30 days and combined urine testing results at the date of interview and during month before interview is presented in Figure 23 The self-reported figure was consistently lower than results from urine testing About 18.3 % of patients reported drug use at months, 9.8% at months, 10.2 % at months and 11.5% at 12 months In contrast, the combined urine tests show that approximately 27.5% used drug at months, 19.3% at months and approximately 20% at one year
The Cohen’s kappa coefficient is used to measure inter-agreement between self-reported illicit drug uses and combined urine testing results The kappa value of implies perfect agreement and values less than 0.2 imply poor agreement Interestingly, the kappa coefficients increase overtime, from 0.08 at months to 0.42 at 12 months The longer patients stay in MMT, the more likely they report their true drug use status
Figure 23: The Cohen’s kappa coefficient agreement between self-reported drug use and urine tests
0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1
3 months
0.08 0.17
0.39 0.42
(28)The drug use figure reflects the general trend in other studies around the world: the rate is low and remains low However, these results not necessarily reflect “relapse” among MMT clients Hai Phong and HCMC Although some clients are using again, actual incidence is low
Figure 23a: Rate of injection in the past months among those continued using drugs 100%
80% 60% 40% 20% 0%
86.94
77.64
52.94 55.45 52.89
3 months
Baseline months months 12 months
Among clients who continued using drugs, the rate of those who were injecting dropped from 87% before treatment to 77.6% after three months The injection rate then continued to reduce to 55.5% and 53% after nine and twelve months, respectively
Frequency of heroin use among post-treatment patients is less often compared to that before treatment: about 0.95 times per day at the end of month 3, to 8.4 times per month at the end of month 6, and then increased back to about 12.3 times per month The remainder usually inhaled the drugs
Additionally, among this sub-group (those who kept injecting), needle sharing in the month before interviews was very low while only three patients reported having done this within the first six months of treatment (about 1.25%) No patients, meanwhile, shared needles from month to month 12 This is in striking comparison to IBBS findings in 2006, which reported that sharing needles and injecting equipment among IDU was 6% in Hai Phong and 35% in HCMC [28]
Sexual activity also increased among MMT patients Forty-seven percent of participants said they had been sexually active in the three months period to enrollment, and after three months, this figure jumped to 57% Then, at six months it was at 63% and at twelve months was at 66%
This increased sexual activity included sex with regular sex partners and commercial / casual partners, who also reported an increase in their own sexual activity Sex with regular partners increased from 45% before treatment to 61% after one year and overall sexual activity with commercial/casual workers increased from 3.1% before treatment to 5.8% after twelve months
Figure 24: Sexual activity over time
70% 60% 50% 40% 30% 20%
46.74
44.97
56.56
52.58
63.36
58.46
65.33 60.62
(29)One point of note here is that consistent condom use with sex workers was at more than 90% after one year of treatment and consistent condom use with regular partners tended to increase from 36.6% prior to treatment to 41.5% after nine months, but decreased to 37.6% at 12 months This rate is higher than the rate of IDUs regularly using condoms when with regular sex partners in other studies (range: 20-30 %)
However, at months, only about 68% of HIV-positive participants said they used condoms “consistently ” and only about 6% said they used condoms “most of the time” with their spouse Thus there is clearly a need to expand communication and counseling about safe sex behaviors at treatment sites
3.6 Physical health, mental health, and quality of life
Overall, quality of life improved considerably for new MMT patients Before MMT, only 16% of participants said they had “good” or “very good” quality of life but at one year, 50.5% answered “good” or “very good” Proportions of patients “pleased with their health” also increased from 31.5% before treatment to around 55.2% during treatment Quality of life scores also improved remarkably, particularly during the first three months
Direct physical health increased too, from 68 to 76 after 12 months and overall mental status of patients also had much higher, from 56 to 70 Social and environmental aspects also improved, but slowly
Biological testing conducted by research team detected new cases of HIV at months and new case at 12 months; cases HBV at months and cases at 12 months; 71 cases HCV at months and 39 cases HCV at 12 months
Figure 25: Proportions of patients with health problems in the 30 days prior to interview 7.46
8.28 7.24 8.61 10.33
15% 10% 5% 0%
Before treatment months months months 12 months
Study staff considered “health problems” to be any health issue that impacted a participant’s health “moderately” or “severely” The percentages of patients with health problems during treatment process were likely to be higher than they were at pre-treatment point
There are a few explanations for this difference The two most common included side effects of methadone, such as constipation; and some clients began starting their ARVs or TB treatment in conjunction with MMT and thus suffered from ARV side effects or immune reconstitution syndrome (IRS)
(30)Table 10: Mental health status over time (from patient’s interview) Before
(%) 3 months months months 12 monthsAfter (%) Difficulty concentrating or
remembering 51.19 30.86 34.86 31.61 32.22
Anxiety, severe tension 32.26 9.35 7.46 6.67 5.99
Depression, hopelessness 44.87 10.43 9.03 7.23 7.40
Severe loss of interest 28.91 8.71 7.47 7.00 7.16
Hallucinations, hearing things 11.50 3.33 3.45 3.21 3.40
Difficulty controlling violent
behavior 18.46 6.88 7.68 5.28 5.63
Thoughts of suicide 15.34 1.08 1.22 0.46 0.23
Attempted suicide 5.29 0.32 0.11 0
Mental health issues dropped significantly for MMT patients Patients having trouble concentrating or remembering dropped from 51% to approximately 30-34%, proportion of anxiety or severe tension dropped from 32% to nearly 6% and hallucinations reduced from 11.5% to about 3.4% A major finding is that thoughts of suicide declined from 15.3 % to 0.2 % after 12 months and while 5.3% of clients had demonstrated thoughts of suicide at baseline, this number went to zero
Figure 26: Average total of Kessler score for patients before MMT and over time 50
40 30 20 10
100 80 60 40 20 %
20.8 21.1
Proportions of patierts whose Kessler scores are from 15 or lower
86.4
12.2 11.2 11.6 11.8
85.9 89.7
95.8
3 months
Before treatment months months 12 months Average Kessler score
Depression among IDUs on MMT also dropped considerably On average, the total Kessler score (for scaling the levels of depression) dropped from 20.8 (which is classified as “moderately or severely depressed”) to 12.2 (“not severe”) at the end of month 3, and then to 11.8 at the end of month 12 Ultimately the rate of clients with no risk of depression (15 or below on Kessler) increased from 21 % before treatment to 90 % by the end of month In the period from month to 12, this proportion decreased to about 86%
Table 11: General evaluation and quality of life and health over time
Before During treatment
3 months months months 12 months Quality of life
• Very bad 1.45 0.32 0.00 0.11 0.00
• Bad 10.88 1.18 1.56 0.80 0.82
• Average (“so-so”) 71.81 46.88 45.88 46.73 48.71
(31)Client satisfaction with own health
• Very unsatisfactory 0.31 0.11 0.22 0.00 0.35
• Unsatisfactory 18.13 5.16 6.01 5.86 5.87
• Average 50.05 33.98 36.86 35.94 38.62
• Satisfactory 29.64 56.99 53.01 54.31 52.58
• Very satisfactory 1.87 3.76 3.90 3.90 2.58
Figure 27: Quality of life for MMT clients before treatment and after 12 months 100% 90% 80% 70% 60% 50% 68 77 76 71 71 67 67 58 59 70 76 76 59 71 66 66 58 59 56 53 months
Before treatment months months 12 months Physical Mental Social Environmental
Still, quality of life can drop again after recovery due to fear of unemployment, pressure to generate income, family pressures, and skewed social or environmental factors, especially social stigma, which could exacerbate these fears Thus, social support, jobs creation, and community re-integration support need to be priority in the next phase of the program
3.7 Social status, and employment status, and crime
Figure 28: Unemployed before treatment over time
35.96 33.66 31.18
27.55 26.96
Month Before
treatment Month Month Month 12
50% 40% 30% 20% 10% 0%
Figure 29: Full-time employment with stable income over time
Month Before
treatment
Month Month Month 12 100% 80% 60% 40% 20% 0%
41.87 43.76 52.67
(32)Unemployment among participants tended to reduce after one year in MMT Thirty-six percent of drug users were unemployed at the outset, and after three months this figure was at 33.7%, and then 27% at 12 months The rates patients employed full time increased from 42% to 55.2% after 12 months of treatment But most of the work was/is simple tasks such as small household business or day labor Only half of the participants had vocational or professional training and it is clear that job training and jobs creation need to be integrated more deeply into the program with significant advocacy to reduce stigma
Figure 30: Incidence of crime over time 50%
40% 30% 20% 10% 0%
Month Before
treatment Month Month Month 12
40.8
2.26 0.8 2.11
Participants were also asked if they had been involved in crime such as theft, fraud, or drug dealing and initially 40.8% stated that they have involved in crime during their lifetime The self-reported criminal rates among those remaining in the cohort were 2.3% after months, 2% after months and 2.11% after 12 months However, this figure is biased since 48 patients were arrested during months of treatment and thus were lost to follow-up The information on those, who were lost to follow-up, was not included
MMT also clearly helped participants reintegrate into society and their families Family conflicts (and conflicts with neighbors and friends) also dropped considerably, from 20% prior to treatment to 3.56% after nine months and then 4.11% after 12 months And where it is common for heroin users to pawn their family’s possessions for drug money, lie, or even force family members to give them money, all of these things dropped significantly, in this case from 90 % prior to treatment to 2.46 % after 12 months of MMT
Figure 31: Proportions of patients, who had experienced serious problems getting along with family or friends over time
Month Before
treatment
Month Month Month 12 20%
15% 10% 5% 0%
19.9
(33)Figure 32: Family conflicts over time (those reported negative activities in family)
Month Before
treatment Month Month Month 12
100% 80% 60% 40% 20% 0%
90.36
9.78 3.45 3.44
2.46
3.8 Access to medical services and social support
Except for increased access to HCT and ARVs, client access to services remained fairly low for different reasons Once on MMT, clients stopped seeking clean needles for example and despite increased sexual activity while on MMT, only about to 10% were being given condoms at clinics
Table 12: MMT clients receiving medical and social support services in the month prior to interview, in %
Before After
3 months months months 12 months
VCT 64.52 62.69 34.45 36.39 27.23
ARV treatment 12.77 11.83 14.60 15.61 14.91
Opportunistic infection
treatment 3.11 3.55 4.68 5.28 5.40
TB treatment 4.05 3.34 3.23 2.99 1.41
Treatment for mental illness 0.1 0.54 0.22 0.11 0.12
Others 4.77 2.90 1.78 1.95 1.76
RDU services 3.32 3.76 4.57 3.21 4.23
Peer education 4.15 6.45 5.35 4.36 3.76
Clean needles and syringes 8.2 5.05 1.56 1.49 0.82
Free condoms 7.47 8.39 7.25 6.54 3.76
Social services 0.62 0.32 0.67 0.69 0.47
Legal services 0.21 0.43 0.11 0.34 0.47
(34)V Limitations of the study
1 Evaluation of an MMT program requires longer time of follow-up as patients experience changes in physical, mental, and social wellbeing well beyond the end of the survey For example, treatment adherence can drop when the treatment is prolonged This phenomenon is common for all drug treatment programs, not only methadone
2 Hai Phong and HCMC clinics in the study had never been participated in similar project and study participants were selected according to certain criteria set by the Ministry of Health and by local authorities They were thus not representative of all IDUs in the two cities Much information was collected through patient’s interview and this invariably introduces
“self-reporting” errors especially when it comes to sensitive information such as drug use or sexual behavior Patients tend to give “favorable” answer rather than the real answer Interviewees also shy away from these subjects and this ultimately skews the data However, guarantees of privacy and confidentiality remove this issue
4 Patient records and counseling documents were incomplete Currently there is no system for tight data management in Vietnam and figures collected in Ngo Quyen (Hai Phong) and District (HCMC) is very limited Such missing information can affect the final outcomes of the study (see below) This was a cohort study, and some drop out participants may also affect the study’s results
VI Conclusions and recommendations 1 Conclusions
1 The rate of patients who stayed in the program remained high after one year of treatment: (88.3 % with a low dropout rate, at 11.7 %)
2 Most patient showed strong adherence to treatment and dropout more than five days (at which point they would need to re-start the whole treatment process) reduced as time passed Methadone side effects reduced over time, from 75.2 % in the first three months to about
60.6% by the end of the 12th month
4 Therapeutic methadone dose were higher (104mg/day) than methadone dosage in similar studies conducted in other countries (USA: 65mg; Australia: 60mg) [32] And in patients co-treated with ARVs, average methadone dosage reached 162mg/day
5 Methadone significantly reduced drug use in patients and among those who did continue using heroin, frequency of injection also reduced For patients on methadone and ARVs, the heroin use remained high regardless of higher methadone dosage
6 The project has documented the rate of risk behaviors for HIV transmission significantly reduced among patients In addition to reduced and lower frequency injection, incidence of needle sharing dropped And while sexual activity did increase, condom use also increased After 24 months follow up, project reported new cases of HIV; 15 new cases of HBV and
110 new cases of HCV
(35)10 Employment also increased more for participants the longer they stayed in treatment course, although overall figures for employment were inconclusive Participants worked mostly for the family business
11 Crime was also very low among study participants, at less than % over 12 months This is significant considering that more than 40 % participants had been involved in crime before enrolling in MMT Family and social conflicts also trended downward, suggesting strongly that MMT is a vital component of community re-integration
12 Rate of patients referred to and using of support services remained low after 12 months, especially social support services and clinics seemed to pay more attention to referring of patients to medical services such as VCT and ART
2 Recommendations
1 Expanding this program to more districts in Hai Phong and HCMC, as well as to more cities and provinces nationwide will bring the positive life changes demonstrated above to more drug users and will bring greater benefits for society This will…
Curb the transmission of HIV/AIDS through by reducing risky injection behaviors
Vastly reduce petty crime
Improve relations in the family and society
Improved quality of life and better health for MMT clients, leading to job opportunities, stable income and community reintegration
2 The study showed a high rate of HIV, hepatitis B, and specially hepatitis C , and there are considerable drug interactions between the medications for these infections and methadone Yet staff at clinics still lack experience inn diagnosis and management of co-morbidities so there needs to be more training on these and on opportunistic infections among PLHIV Also, to ensure the quality of treatment, there should be more training on referrals for health staff working at facilities outside the MMT-IDU network
3 The rate of patients on ARVs who still used drugs remained high after 12months of MMT and methadone guidelines should be revised to focus more on dosage increases, standards to determine the methadone stable dose period, technical discussions on “high” dosage; and monitoring of patients on ARVs and other drugs that interact with methadone
4 A high number of patients who stopped MMT early were then arrested or re-arrested and this suggests a need to review patient selection criteria, especially in HCMC Treatment “courses” (including methadone dosing and counseling) also need to be further revised to be in line with special patients at higher risk of relapse and possible incarceration in government “06” centers Local authorities should offer more support to MMT clients, especially social support
programs that focus on:
Strengthening social support services including vocational training and jobs creation
Strengthening communication to reduce stigma and discrimination while creating conditions for IDUs them to reintegrate into the society This would include educate on safe sex and condoms
(36)RefeRenCes
1 UNAIDS, 2008 Report on the global IADS epidemic Available at http://www.unaids.org/en/ KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp 2009
2 Ministry of Public Security, Report on prevention and control of drugs in 2008and focal work plan for 2009 Report at the 2008 annual review meeting on “Prevention and control of drugs abuse, prostitution and work plan for 2009” in Hanoi, Vietnam, 2009
3 Nguyen AT, N.T., Pham KC, Le TG, Bui DT, Hoang TL, Saidel T, Detels R, Intravenous drug use among street-based sex workers: a high-risk behavior for HIV transmission Sex Transm Dis., 2004 31(1): p 15-9
4 Nguyen, T.A., et al., Risk factors for HIV-1 seropositivity in drug users under 30 years old in Haiphong, Vietnam Addiction, 2001 96(3): p 405-13
5 Ministry of Health - Vietnam Administration of HIV/AIDS Control, Viet Nam HIV/AIDS Estimates and Projections 2007 - 2012 Available at http://www.unaids.org.vn/sitee/images/ stories/EPP%20report%20EN.pdf 2009
6 Metzger DS, W.G., McLellan AT, O’Brien CP, Druley P, Navaline H, DePhilippis D, Stolley P, Abrutyn E, Human immunodeficiency virus seroconversion among intravenous drug users in- and out-of-treatment: an 18-month prospective follow-up J Acquir Immune Defic Syndr., 1993 6(9): p 1049-56
7 Kwiatkowski CF, B.R., Methadone maintenance as HIV risk reduction with street-recruited injecting drug users J Acquir Immune Defic Syndr., 2001 26(5): p 483-9
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