AIDS lần thứ IV năm 2010

The objective of this study was to examine the risk behaviors and their determinants among Male Injecting Drug Users (IDUs), especially focusing on the effect of an HIV/AIDS intervention[r]

HIV Transmission from Men to Women in Intimate Partner Relationships in Viet Nam

Authors:

Kathleen Selvaggio – UNIFEM Nguyen Thi My Linh – UNAIDS Hoang Tu Anh – CCIHP

ABSTRACT:

In 2009, the ratio of male to female adults living with HIV was estimated to be three to one and is estimated to gradually decrease, reaching 2.6 by 2012 The increasing ratio of infections among women is believed to reflect growing transmission from HIV-infected men engaged in high-risk behaviours injecting drug users (IDUs) and clients of sex workers to their wives or regular sexual partners

Insufficient data and research on “intimate partner transmission” is one of the main challenges in measuring the scope of this issue and its impact on different groups of men and women Research on male IDUs has focused more on their needle-sharing behaviour and unprotected sex with sex workers rather than with their wives or girlfriends There is little or no data from population-based studies on the proportion of men who visit sex workers in Viet Nam, nor on their use of condoms with wives or girlfriends Although behavioural surveys indicate that a significant share of men who have sex with men also have sex with wives or female partners, there is little information on sexual behaviour and risk in these intimate partner relationships

A key recommendation is to prioritise operations and behavioural research on HIV transmission from key populations at higher risk to their intimate partners, and to include indicators on intimate partners in national-level data

I. INTRODUCTION:

Asia has seen a major increase in the number of women living with HIV over the past decade, with women making up 35 per cent of new infections, an increase of per cent since 2000 Although some women acquired HIV through injecting drug use and others while selling sex, the majority were exposed while having sex with a husband or partner who had contracted HIV through injecting drug use, through unprotected sex with a sex worker or through unprotected sex with a male partner This is known as HIV transmission in intimate partner relationships, or “IPT”

There are preliminary indications that this pattern is also occurring in Viet Nam In 2009, it was estimated that 243,000 people in Viet Nam were living with HIV, with prevalence among adults (ages 15 to 49) at 0.43 per cent of the population HIV infection is still heavily concentrated among men who use drugs or engage in other high-risk behaviours In 2009, the number of male adults living with HIV was three times higher than the number of female adults living with HIV, and men still make up the majority of new infections However, it is estimated that the male-female ratio will gradually decrease, reaching 2.6 by 2012, possibly reflecting rising rates of transmission from HIV-positive men who are injecting drug users (IDUs), clients of sex workers, or men who have sex with men to their female spouses or regular sexual partners

In order to help policy makers and programme planners better understand the situation and design evidence-based policies and programmes to prevent intimate partner transmission of HIV, the Joint UN Team on HIV commissioned desk and field-based research on intimate partner transmission (IPT) from men to women in Viet Nam This study aimed to describe the risk of IPT in Viet Nam (including the common occurrence of domestic violence), uncover the barriers to and enabling factors for effective HIV prevention, and assess how IPT is addressed in current HIV-related policies and intervention programmes Based partly upon this research, a joint UN discussion paper on male-to-female intimate partner transmission in Viet Nam was published in mid-2010 It identified insufficient data as one of the main challenges in measuring the scope of this issue and its impact on different groups of men and women

II METHODOLOGY:

policy/legal documents, research papers, project/programme documents and Information Education Communication (IEC) and Behaviour Change Communication (BCC) materials; (2) self-administrated survey that collected information on intervention programmes related to intimate partner transmission; (3) qualitative study of men with high risk behaviours, female spouses of men with high risk behaviours, voluntary testing and counselling (VCT) counsellors and key staff from organizations working in the field of HIV service delivery

Based on preliminary findings, researchers collected more studies and data on attitudes and practices of condom use, gender-based violence and its role in HIV infection, and gender norms and behaviour in sexual and family relations

III FINDINGS General

Insufficient data and research hampers efforts to measure the risk of IPT from men in Viet Nam who engage in high-risk behaviours – unsafe drug injection, unprotected sex with FSWs and unprotected sex with men – to their female partners

Male injecting drug users

Studies show that significant numbers of male IDUs have unprotected sex with different partners, including female sex workers At the same time, many reported having regular female sexual partners in the previous 12 months (28 per cent of IDUs in Hai Phong and 60 per cent in Hanoi) Few of these IDUs (16-36 per cent) reported using condoms consistently with their regular partners (MOH 2006, p.50) However, these data are insufficient to draw firm conclusions A rapid assessment of other research on IDUs also suggests that most studies have focused on needle sharing and unprotected sex among IDUs or between IDUs and sex workers, rather than on their sexual behaviours with intimate partners (Hoang et al 2010)

Male clients of female sex workers

Male clients of FSWs are significant agents in the transmission of HIV, yet a rapid assessment of current research on this population indicates that most studies have focused only on their behaviours with female sex workers rather than bridging behaviours with intimate partners (Hoang et al 2010) A study in Ha Noi in 2002 indicated that one-third of men aged 18-55 had sex with an FSW at least once in their life and 45.3 per cent of these had visited sex workers more than five times (Nguyen et al 2008) But only 36.4 per cent of this group reported that they “always” used condoms Findings from the IBBS 2005-2006 also indicated that few sex workers reported consistent condom use with their regular partners In almost all provinces the rate was 30 per cent or less

Men who have sex with men

In 2006, the IBBS found that 90 percent of HIV-positive MSM were unaware of their status and only 16 per cent reported having had a voluntary HIV test in the last year (MOH 2006) The IBBS also found that only 29 per cent of MSM in Ha Noi and 37 per cent in Ho Chi Minh City reported the consistent use of condoms with non-commercial partners in the previous month This combination of a lack of awareness of HIV status and inconsistent condom use presents a clear risk to intimate partners According to the IBBS, in the 12 months prior to the survey about 40 per cent of MSM had had sex with a female partner A rapid assessment of available literature indicated that there is little information available on these relationships or behaviours, or the risks that female partners of MSM and female intimate partners of male clients of MSM face (Hoang et al 2010)

Male migrant workers

Young male migrants who work in the construction, industrial or manufacturing sectors far away from home are more vulnerable to HIV because they have a tendency to engage in unprotected sex with more than one partner as well as a tendency to use injecting drugs Their female intimate partners are thus vulnerable to IPT (UNFPA, forthcoming) A behavioural survey carried out in 2000 with about 2,500 migrant workers in Viet Nam found that 60 per cent of respondents were married Nevertheless, in Hai Phong 20 per cent and in Can Tho per cent had had at least one commercial sex partner in the previous 12 months Consistency of condom use among these respondents varied depending on the location and the type of partnership, but with wives/regular partners it was less than 3per cent

Limitations in data collection

male IDUs, it does not extend to other groups likely to engage in high-risk behaviours, such as the male clients of female sex workers and male migrant workers In addition, there are no national-level data on the number of individuals among these key populations at higher risk who are married, and no data on their condom use habits or other sexual behaviours with their wives or intimate partners, though some small-scale studies have addressed these issues

Not all official national HIV data has been sex-disaggregated, making it difficult to measure differences among men and women The Government of Viet Nam recently adopted a decision requiring sex-disaggregated data at the national, provincial and district levels, but concerns remain that the decision lacks enforcement When surveys collect sex-disaggregated data, reports often not present the breakdown by sex but instead re-aggregate the data for official publication

IV DISCUSSION

Insufficient data and research has limited the policy and programme responses To date no Vietnamese programmes and policies directly address IPT HIV programmes and policies only indirectly raise the issue of IPT and they not address male responsibility to protect intimate partners Nor they confront gender inequalities and norms that may increase women’s vulnerability to infection HIV prevention programmes tend to focus on strategies for self-protection and few address individuals’ responsibility to protect their intimate partners or confront sensitive issues of gender power imbalance in sexual relationships HIV and reproductive health laws and policies not yet adequately challenge power relations between men and women, particularly in sexual relationships However, there are signs within the policy environment in Viet Nam that decision makers might be ready to address gender inequality issues underlying IPT, such as the recent promulgation of the Law on Gender Equality and the Law on Domestic Violence Prevention and Control

V. CONCLUSION

Although Viet Nam has a concentrated epidemic, the male-to-female ratio of people living with HIV is decreasing As such, HIV transmission from men to women in intimate partner relationships should be considered an important element in the national response to HIV Insufficient data is one of the main challenges in measuring the scope of this issue and its impact on different groups of men and women This in turn has limited the policy and programme responses

In order to strengthen the body of evidence in Viet Nam on the extent and nature of HIV transmission in intimate partner relationships, it is important to fully implement Government regulations on national- and provincial-level HIV prevalence data be disaggregated by sex and age Official Government reports need to standardize the use of this disaggregated data

Another key recommendation is to prioritize operations and behavioural research on HIV transmission from key populations at higher risk to their intimate partners This should include: 1) population-based studies investigating intimate partner transmission among IDUs, MSM, male and female sex workers, male clients of sex workers, male migrants and their intimate partners; 2) more qualitative studies on sexual behaviour and communication among those at higher risk of HIV and their intimate partners, exploring gender differences that affect their behaviour and communication; and 3) qualitative studies to investigate risk behaviours among pregnant women who test positive for HIV

References

Hoang, T H., Nguyen, N T., Nguyen V T (2010) Spousal Transmission of HIV among Married Women in Viet Nam: Review of policies, research, interventions and IEC materials Ha Noi UNAIDS and CIHP

Nguyen, T.A., Oosterhoff, P., Hardon, A Nguyen, T.H., Coutinho, R.A., Wright, P (2008) A Hidden HIV epidemic among women in Viet Nam BMC Public Health 8(37)

Ministry of Health, Viet Nam (2006) Results from HIV/STI integrated biological and behavioural surveillance (IBBS) Viet Nam 2005-2006 Ha Noi

DRUG USE AND RISK AMONG MEN WHO HAVE SEX WITH MEN, MALE SEX WORKERS AND TRANSGENDER

IN HANOI AND HO CHI MINH CITY

Authors: Vu Ngoc Bao (FHI), Philippe Girault, Kevin P Mulvey, Nguyen Thanh Son, Tran Thi Bich Lien, Phan Thi Uyen, Le Cao Dung, Ta Thi Hong Hanh, and Nguyen Anh Ngoc

I Background: HIV infection among men who have sex with men (MSM) and transgender persons (TG) is increasing in many countries in the Asia-Pacific region Evidence also shows that MSM have significant levels of drug use, particularly amphetamine-type stimulants (ATS) In Vietnam, the association between HIV infection and injection drug use among MSM, male sex workers (MSW), and TG has been well documented However, information is lacking on non-injection drug use and its relation to HIV infection to inform the design of targeted interventions for these most-at-risk populations

II Subjects and Methods: A qualitative study was conducted in 2009 in Hanoi and Ho Chi Minh City (HCMC) Qualitative data were collected from MSM, MSW and TG living in Hanoi and HCMC Data collection included 62 in-depth interviews (IDI) with males aged 19-41 years (mean = 26.7) who reported having had sex with another male at least once in the previous 12 months and who used any type of drug other than alcohol in the past month (i.e 34 MSW, 23 MSM and TG) It also included 15 IDI with non-drug users who were friends of the drug users (i.e MSW, MSM and TG), four focus group discussions with MSM, MSW and TG, and nine key informant interviews with local stakeholders representing drug control, drug treatment, and HIV/AIDS intervention agencies at provincial and district levels

III Results:

Patterns of drug use: Polydrug use (use of more than one drug in a drug session or sequentially) is common among MSM, MSW and TG, accounting for about two thirds of the respondents using drugs (42/62) Different types of drugs, including heroin, ecstasy, ice, ketamine and marijuana, are used Respondents described sophisticated patterns of use, including combining drugs to enhance their effects (i.e ecstasy plus ketamine or marijuana to enhance ‘sexual pleasure’), or to reduce negative effects (i.e., ecstasy plus ketamine and ice to reduce ‘coming down’) The contexts for drug use vary based on MSM/MSW/TG perceptions of how best to enjoy the specific drugs For example, heroin is used in private or discrete venues (e.g private homes, homes of friends, dark corners and public toilets) Ice and ketamine are often used in private venues such as homes, guesthouses or hotels Ecstasy is used in indoor public venues (e.g discos, bars and karaoke lounges), whereas marijuana is used in outdoor public venues like streets, river and lake banks, and teashops

Key reasons for drug use: Respondents reported pleasure seeking and coping with emotional issues (e.g self-stigma) as key reasons for initiating drug use They also face peer pressure to use Many reported being curious about what they would feel like experimenting with drugs while socializing with peers Unlike heroin, other drugs are considered as ‘recreational drugs’ (particularly ATS) Drugs were used as a means to cope with emotional issues such as lack of compassion, care and love from family members and neighbours, stigmatization, self-stigmatizing attitudes on sexuality, and difficulty in disclosing sexual orientation

Sexual risk behaviors: Intoxication is associated with unsafe sex (i.e unprotected receptive and insertive anal sex) among respondents Condoms frequently are not used during sex with both male and female sex partners because respondents not think of using them when high Group sex is a common activity when MSM, MSW and TG use drugs among groups of friends Drugs are used as sexual enhancers to stimulate sexual desire and prolong sexual intercourse These drugs include ice, ecstasy, ketamine and heroin (non-injected)

Sex work and drug use: There is a link between sex work and drug use particularly heroin injection MSW use drugs to facilitate their sex work, and drug users trade sex for drugs Many have unprotected sex with their clients MSW use drugs to support their sex work Drugs help them stimulate sexual desire, increase stamina, and increase confidence when approaching and negotiating with clients Drug users sell sex as a last choice to purchase drugs

Quitting drug use: There is a growing realization among respondents who use drugs that it is very difficult to quit heroin This realization is based on respondents’ own experiences, or those of their friends’, in failing to quit heroin after attending government treatment and education centers (commonly known as ‘06 centers”’) or private drug treatment centers In contrast, those who use other drugs like ecstasy, ice, ketamine, marijuana and glue not perceive the need to quit these drugs because they are considered non-dependence-forming substances

Access to health services including drug treatment: Due to their drug use and sexual orientation, MSM/MSW/TG face double stigma and are less likely to seek out government health services, including drug treatment (community support and recovery centers and 06 centers), and methadone maintenance therapy (MMT) Respondents and key informants alike perceived these service provision agencies as stigmatizing and lacking in MSM-friendly services

IV Discussion

Polydrug use is common among the respondents in this study They use various types of drugs, including heroin in addition to one-to-four other drugs, or at least two different drugs in combination or sequentially These findings are consistent with cross-sectional surveys among gay, bisexual and heterosexually identified MSM populations in western countries (Stall and Wiley 1988; Clatts, Goldsamt and Yi 2005; Jerome, Halkitis and Coley 2009)

Findings reported in previous studies in Hanoi and HCMC (Clatts, Goldsamt and Le 2007; Nguyen, Nguyen and Le 2008) reveal that injection drug use is significant among MSM, particularly among MSW, and sharing needles and syringes is common in situations where funding is short or there is no easy access to sterile needles Consistent, and/or facilitated access to sterile needles and syringes is still problematic in Vietnam

This study provides empirical evidence that MSM/MSW/TG who use drugs often engage in high-risk sexual behavior (i.e unprotected and prolonged receptive and insertive anal sex with multiple partners) This high-risk sexual behavior is influenced by the use of drugs: respondents admit that they often fail to use a condom when they are high This finding is consistent with several studies that have found a statistical relationship between substance use during sex and the likelihood of participating in high-risk sex (see Stall and Purcell 2000, for a review of literature; Mansergh, Shouse and Marks 2006)

Findings from this study also indicate that drug use has a number of sexual purposes Ice, ecstasy, ketamine and heroin are commonly used as sexual enhancers to stimulate sexual desire and prolong sexual intercourse Drugs are also used to help users reconcile same-sex behavior and to maintain sexual partnerships with cohabitant or regular partners These findings are somewhat consistent with a qualitative study in the United States that revealed that drug use plays a central role in same-sex sexuality for many African American MSM and MSW Respondents in that study described alcohol and drugs as motivators for sex with men, rationalizing same-sex behavior and unprotected sex, and facilitatingaccess to male sex partners (Harawa, Williams and Ramamurthi 2008)

This study also provides critical insight into the reasons for initiation and continuation of drug use that may lead to substantially different patterns of drug use between MSM, TG, MSW, and other men These reasons are consistent with those found in a review of literature on substance use among MSM and its link to the AIDS epidemic (see Stall and Purcell 2000) While the two main reasons for initiation of drug use are related (escape from negative feelings, and pleasure), negative feelings take root in different ways among MSM, MSW and TG MSM and TG report negative feelings related to their sexual orientation including: lack of compassion, care and love from their family members and neighbors, stigmatization, negative attitudes towards their sexual orientation, and difficulty in disclosing their sexual orientation Conversely, MSW (self-identified straight men) report negative feelings related to their unhappy partnerships with their girlfriends or wives Perceived benefits that motivate continuation of drug use also vary by sub-group While MSM, TG and MSW shared common perceived benefits (i.e entertainment, sexual enhancement, stamina and pain relief), MSM and TG were more likely than MSW to report other benefits, such as reinforcement of their masculinity and self-confidence, and weight control

V Conclusions and recommendations: This study highlights the need for drug-related risk/harm reduction interventions to be integrated into existing sexual risk reduction MSM interventions to reduce or prevent the spread of HIV infection and other health-related risks among MSM, MSW, and TG in Vietnam

Risk/harm reduction interventions: Drug-related risk/harm reduction interventions must be integrated into existing MSM interventions These interventions should be aimed in increasing the access to commodities including sterile syringes and needles, and condoms and water-based lubricant, in reaching different networks of MSM using drugs, establishing linkages to relevant services, and in building the capacity of MSM outreach workers and drop-in center staff in integrating these activities in their current MSM interventions

MSM-friendly services: Health and drug counseling/treatment services need to be made more MSM-friendly by sensitizing health care providers and support staff working in specific clinics or centers providing HIV/STI or drug-related services (e.g methadone maintenance therapy and recovery centers), on MSM and TG sexuality and sexual health needs

References

Clatts, M.C., Goldsamt, L.A., & Yi, H (2005) Club Drug Use among Young Men Who Have Sex with Men in NYC: A Preliminary Epidemiological Profile Substance Use & Misuse 40 (9-10): 1317– 1330

Clatts, M.C., Le, G.M., Goldsamt, L.A., & Yi, H (2007) Male sex work and HIV risk among young heroin users in Hanoi, Vietnam Sexual Health, 4, 261-267

Harawa, N.T., Williams, J.K., Ramamurthi, H.C., Manago, C., Avina, S., & Jones, M (2008) Sexual Behavior, Sexual Identity, and Substance Abuse Among Low-Income Bisexual and Non-Gay-Identifying African American Men Who Have Sex with Men Arch Sex Behav 37(5), 748-762

men in the USA Sex.Transm Inf 84, 509-511

Mansergh, G., Shouse, R.L., Marks, G., Guzman, R., Rader, M., Buchbinder, S., & Colfax, G.N (2006) Methamphetamine and sildenafil (Viagra) use are linked to unprotected receptive and insertive anal sex, respectively, in a sample of men who have sex with men Sex.Transm Inf 82, 131-134

Newman, P.A., Rhodes, F., & Weiss, R.E (2004) Correlates of Sex Trading Among Drug-Using Men Who Have Sex With Men Am J Public Health 94(11), 1998–2003

Nguyen, T.A., Nguyen, H.T., Le, G.T., & Detels, R (2008) Prevalence and risk factors associated with HIV infection among MSM in Ho Chi Minh City, Vietnam AIDS Behav 12, 476-482

Stall, R., & Wiley, J (1988) A comparison of alcohol and drug use patterns of homosexual and heterosexual men: The San Fransisco Men’s Health Study Drug and Alcohol Dependence 22, 63-73

Jerome, R.C., Halkitis, P.N., Coley, M.A., & the Hope Team (2009) Methamphetamine use patterns among urban Black men who have sex with men Culture, Health and Sexuality 11(4), 399-413

Stall, R., & Purcell, D (2000) Intertwining epidemics: A review of research on substance use among men who have sex with men and its connection to the AIDS epidemic AIDS Behavior 4,181-192

Behavioral survey on condom use and HIV Voluntary Counseling and Testing uptake among male clients

of female sex workers in 2009 in Vietnam Duong Le Quyen, Vu Ngoc Khanh, Yasmin Madan, Gary Mundy

Population Services International (PSI) Summary

With the President’s Emergency Plan for AIDS Relief (PEPFAR) funding through the United States Agency for International Development (USAID), PSI Vietnam is implementing a comprehensive HIV prevention program targeting male clients of female sex workers (FSW) The program is implemented in partnership with the Provincial Health Departments (PHD) and Provincial AIDS Centers/Committees (PAC) in seven high HIV prevalence provinces in Vietnam In 2009, PSI partnered with a local research agency, Consultation of Investment in Health Promotion (CIHP), to conduct the second round of a behavioral survey among male clients of FSW The survey aimed to identify key behavioral determinants for the promoted behaviors and to evaluate impact of the program activities

I Background

HIV prevalence among FSW and their male clients in 2007 in Vietnam is estimated at 9% and 2% respectively1 Because of the large number, male clients of FSW account for the largest number of new HIV infections1,3 These men face a substantial risk of transmission of HIV and sexually transmitted infections, and also present a risk of transmission to their regular sex partners Strong prevention efforts are required to reduce risk for this population1

With PEPFAR funding through USAID, PSI is implementing a comprehensive HIV prevention program targeting male clients of FSW in seven high HIV prevalence provinces in Vietnam The objectives of the program include: increased correct and consistent condom use in high risk relationships (commercial and casual partners), reduced multiple partnerships, and increased uptake of HIV voluntary counseling and testing (VCT) services This program uses an integrated behavior change communication approach that includes mass media campaigns and outreach activities conducted in entertainment establishments such as quán bia (beer halls) and quán nhậu (popular restaurants) This program is implemented in partnership with PHD and PAC in each target province

In 2008, PSI conducted a behavioral survey among male clients of FSW in targeted entertainment establishments in Hanoi and Ho Chi Minh city5 Male clients of FSW were defined as men who reported sex with FSW in the last three months The survey findings showed that 85% of male clients reported consistent condom use with FSW during vaginal sex in the last three months Logistic regression was used to identify the significant factors that influence promoted behaviors

PSI behavior change framework organizes potential determinants of behavior change into 16 factors4 Those factors considered most relevant to the behavior/intervention are entered into a logistic regression analysis, using a combination of scaled constructs and individual scaled items (four-point Likert scale) The logistic regression analysis is then used to identify the combination of factors that have the strongest influence on the behavior

In June and July 2009, PSI conducted the second round of a behavioral survey among male clients of FSW The objectives of this study were:

1) To identify the extent of HIV risk behaviors and uptake of VCT services among male clients of FSW;

2) To identify key determinants of consistent condom use and to provide a profile of inconsistent condom users;

3) To evaluate the impact of the Male Client intervention across communication channels used in the program

II Study participants and methodology

recruited Table presents the sample size distribution by provinces in this study Potential participants were screened on the following criteria: (i) reported having sex with FSW in the last three months; (ii) 18 – 40 years old; (iii) having lived in the district in the last six months; (iv) did not attend any study related to HIV in the last six months; and (v) sitting in the entertainment establishments alone or only in male group

Table Sample size distribution by provinces

Provinces Male population at

intervention districts2 Sample size

Hanoi 623,621 495

Hai Phong 264,062 203

Quang Ninh 98,097 101

Nghe An 114,766 101

Ho Chi Minh city 581,087 450

Can Tho 187,834 149

An Giang 129,414 103

Total 1,998,881 1,602

After identifying eligible men, a structured questionnaire was used by the same interviewers Descriptive analysis and multi-variate analysis with UNIANOVA and logistic regression model with a level of significance at 0.05 were used

III Research output

Table shows the screening process to recruit the respondents for this survey The mean age of respondents was 29 years Majority of them (58%) attended above high school Nearly half of respondents were married and 42% had children Thirty-six percent reported working as manual labor, while 35% are white-collar workers Their average personal income in the last six months was five million Vietnam dong per month

Table Screening summary

Indicators In seven provinces

Number of men approached in targeted entertainment establishments 7,526 Percentage of men who agreed to be screened 73%

Number of men who agreed to be screened 5,485 Percentage of men who met demographic criteria (criteria number 2, 3,

mentioned above)

82% Number of men who met demographic criteria 4,497 Percentage of men who had vaginal sex with FSW in the last three months 39% 1 Condom use in commercial sex

On average, respondents reported sex with three FSW in the last three months and the average number of sex acts with FSW was six over the same period Eighty-seven percents reported consistent condom use during vaginal sex with FSW in the last three months

Five factors from PSI behavior change framework were identified as being significant determinants of consistent condom use The statements are listed below, together with the factor from PSI behavior change framework and the Odds Ratio score for each item

i Availability of condoms at place where sex with FSW takes place (Availability): OR = 1.54; ii Every 15 minutes, one more person gets HIV in Vietnam (Knowledge): OR = 1.43;

iii I can get HIV if I have sex with sex worker without a condom just once or twice (Attitude): OR = 1.37;

v Even after drinking remember that I have to use a condom with a sex worker (Locus of Control): OR = 1.59;

vi When I am aroused I not remember to use a condom with a sex worker (Locus of control): OR = 1.57

2 Uptake of VCT service

Figure HIV test among male clients of FSW

Figure presents percentage of respondents getting HIV tested Forty percent reported ever tested for HIV tested This includes respondents reporting being tested at different health facility settings and at VCT centers Only 13% reported testing for HIV at the VCT sites Reasons for not getting testing among respondents who have never got HIV tested, 85% believe that they are not HIV-infected while 7% are afraid to know the positive result

3 Evaluation of the PSI Male Client program activities

Seventy-one percent of respondents reported ever having been exposed to the mass media campaigns Sixteen percent reported exposure to the outreach activities in the last 12 months with a mean number of 2.7 exposures Among respondents who reported exposure to the outreach activities, 88% were also exposed to the mass media campaign

Figure shows significant impact of the program on behavior change among male clients of FSW A combination of mass media and outreach activities (especially repeat exposure) was significantly associated with consistent condom use with FSW in the last three months A significant association was also found between exposure to the intervention activities and use of VCT services in the last 12 months

Figure Impact of the Male Client intervention on the promoted behaviors IV Discussion

screening data showed that the current outreach activities ensure targeting efficiency as a high proportion of targeted men reported having sex with FSW in the last three months

The percentage of male clients who reported using condom with FSW consistently in the last three month is relatively high, but, given the relatively high estimated HIV prevalence rates among FSW in Vietnam (9% in 20071), inconsistent use with FSW poses a substantial risk of HIV transmission This finding is similar to the previous behavioral survey among male clients of FSW conducted by PSI in 20085 The key determinants of consistent condom use found in this study suggest communication themes for behavior communication change program to promote safe sex behaviors among these male clients

Less than half of male clients have ever been HIV tested Of these, more than 50% received testing without pre-test or post-test counseling VCT provides the opportunity for people to know their HIV status with quality counseling support Counseling sessions helps people with negative test result to adopt safe practices to remain negative while helping infected people to seek adequate treatment and care6.

The data presented here shows an association between exposure to PSI’s intervention activities and key behaviors promoted by the program As condom use with FSW is already high, a combination of mass media and outreach activities (especially repeat exposure) are needed to gain further increases in promoted behaviors The proportion of male clients reporting use of VCT services is low, and the data presented suggests that mass media alone can be effective in promoting greater take up of VCT services, but that mass media combined with more intensive outreach interventions are a powerful combination

V Conclusions and Recommendations

PSI’s intervention activities are reaching those men at high risk of HIV transmission The program needs to significantly increase coverage of outreach activities and also achieve high overlap with the mass media campaign to ensure positive behavior change Based on the difference in attitude between consistent condom users and inconsistent users, the programmers can design suitable communication messages to motivate the target group expose to the intervention activities repeatedly

References

1 Bộ Y tế (2009) Ước tính dự báo nhiễm HIV/AIDS Việt Nam năm 2007-2012

2 Tổng cục Thống kê (2006) Tư liệu Kinh tế - Xã hội 671 huyện, quận, thị xã, thành phố thuộc tỉnh Việt Nam Nhà xuất Thống kê

3 Analysis and Advocacy project (2006) Combining epidemiology and economic analysis to inform the response to the HIV epidemic in Ho Chi Minh city

4 PSI (2004) PSI Behavior Change Framework “Bubbles”: Proposed Revision Concept paper PSI/Vietnam (2008) Vietnam (2008): HIV TRaC study evaluating condom use behaviors and determinants among male clients of sex workers in Vietnam

6 United Nation Population Fund (UNFPA) website Preventing HIV infection – Voluntary counseling and testing (VCT) for HIV prevention

The initiation into injecting drug use and the role of male Injecting Drug Users (IDU), a behavioral study

among IDU in the provinces in Vietnam

Vu Ngoc Khanh, Pham Duc Tung, Gary Mundy, Duong Le Quyen, Le Thi Linh Chi, Yasmin Madan

Population Services International (PSI) Summary

PSI Vietnam is implementing the Break The Cycle (BTC) intervention which aims to discourage IDU from initiating non-injectors into injecting This intervention is a component of the Drug Demand Reduction (DDR) program, funded by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID) In 2010, PSI partnered with a local agency, NewCare JSC, to conduct a quantitative survey among male IDU in seven high HIV prevalence provinces in Vietnam The findings from this study confirmed three behaviors in the BTC model through which IDU initiate non-injectors into injecting In addition, the study identified the inter-linkages between these behaviors and provided baseline data for the program intervention

Background

Injecting drug use remains the main reason driving the concentrated HIV epidemic in Vietnam According to the 2009 Integrated Biological and Behavioral Sentinel Survey, HIV prevalence among injecting drug users (IDU) is higher than any other most at-risk population group In seven provinces, HIV prevalence among male IDU was 20% and in three provinces the prevalence was much higher at 45%8 To reduce new HIV infections, it is critical to maintain focus on this target group

Current programs in Vietnam aim to reduce risky injecting and sexual practices in this target group However, there are limited programs addressing drug demand reduction and no programs targeting reduction in initiation into injecting drug use The Break The Cycle (BTC) model, first introduced and implemented in the UK, is an innovative research-based approach to reduce the number of injecting drug users1 BTC provides a supplement preventive approach to existing drug-demand reduction programs, increases chance of having more important impact on reducing injecting drug and the spread of HIV globally The BTC targets current IDU to address the initiation process with the aim of preventing initiation of non-injecting drug users into injecting drug use The theoretical basis of BTC model is derived from evidence from many countries that current injecting drug users play an important role in new injectors’ decision to start injecting5 The BTC model outlines three ways through which IDU initiate non-injectors into injecting:

- Help non-injectors with their first injection (H) - Inject in the presence of non-injectors (I)

- Talk about the benefits of injecting in front of non-injectors (T)

These behaviors are collectively referred to as ‘HIT’ behaviors As injecting heroin can be a complex activity, without assistance from IDU, new injectors can find it difficult to inject for the first time Existing evidence from research studies in Uzbekistan, Kyrgyzstan, and England shows that that more than 80% of IDU report being helped for the first injection by other IDU2-3, 6 Injecting in the presence of other drug users normalizes and models injecting behavior, also provokes curiosity about injecting Repeated exposure to drug injecting is identified as the main precursor factor that impacts the decision of a non-injecting drug users to switch into injecting drug Talking about the “perceived benefits” of injecting has an intuitive influence on other drug users These benefits of switching from inhaling to injecting are almost influential as non-injectors perceive them immediately, such as a more sensational high experienced through injecting, lower cost if injecting, and more convenience with injecting However, there are longer-term consequences that eventually negate these short-term benefits

of the existing IDU were initiated to injecting by an IDU for their first injection Qualitative research also confirmed the HIT behaviors as playing a key role in informing the transition into injecting drug use among inhalers

PSI’s BTC program in Vietnam is implemented in partnership with Provincial Health Departments (PHD) and Provincial AIDS Centers (PAC) in all project provinces PSI provides technical assistance in form of training, evidence-based communication materials and field support to the network of peer educators and outreach workers PSI’s strategy to implement the BTC model is through integration into existing programs targeting IDU PSI’s BTC communication strategy aims to increase awareness among IDU of the behaviors that influence initiation, equip them with skills to refuse to help non-injector with their first injection and encourage them to play a positive role by talking about the negative aspects of injecting drug use (instead of the benefits)

This paper will discuss in detail findings from the Behavior Survey conducted among male IDU in seven (7) project provinces in 2010 These findings further confirm the HIT behaviors, help identify the inter-linkages between these behaviors and provide baseline data for the program intervention

Objectives of the Male IDU Behavior Survey

The survey aims to better understand the role of IDU in initiating non-injectors into injecting The specific research objectives are:

1. To measure the prevalence of the three HIT behaviors among existing IDU that lead to initiation of new users

2. To understand why IDU help smokers to start to inject in order to inform communication strategy

Methodology

The field data collection was conducted in January and February 2010 with a total sample size of 1,093 male IDU in provinces of Vietnam (Hanoi, Hai Phong, Quang Ninh, Nghe An, Ho Chi Minh city, Can Tho and An Giang)

In order to participate in the study, respondents must meet the following criteria:  age 18-40 years

 has been living at least months in the survey provinces  report injecting illicit drugs in the last month

 have injecting experience at least months and not more than 10 years  are not peer educators and outreach workers of programs for IDU or HIV The survey participants were recruited with Respondent Driven Sampling (RDS) A structured questionnaire was used with face-to-face interview

PSI behavior change framework organizes potential determinants of behavior change into 16 factors called OAM determinants (Opportunity, Ability and Motivation)5 Those factors considered most relevant to the behavior/intervention are entered into a logistic regression analysis, using a combination of scaled constructs, individual scaled items (four-point Likert scale) The logistic regression analysis is then used to identify the combination of factors that have the strongest influence on the behavior

The analysis on determinants of HIT behaviors is done with explorative factor analysis and multivariate logistic regression model, in which HIT behaviors are dependent variables and OAM determinants are independent ones with the control for demographic characteristics and other confounding factors In order to correct for biases of RDS, Respondent Driven Sampling Analysis Tool (RDSAT) software version 6.0.1 was used for descriptive data analysis, and for producing the individualized weight for multivariate analysis

Key findings Drug experiences

Almost all of IDU smoked heroin before switching to inject The average duration of injecting was 4.4 years and 83% reported injecting everyday A large proportion of the respondents (89%) reported having smoked heroin before injecting Among these the average smoking duration was 2.3 years before switching to injecting 14% of them reported shared needle/syringe at least one time in the month prior to the study

86% of IDU reported receiving help from other IDU the first time they injected, and 94% of all IDU reported actively asking for help from IDU

HIT behaviors in the past months among the IDU in the survey are shown below:

All HIT behaviors were highly prevalent among the respondents 70% of IDU reported doing at least one of the three behaviors in the past months 26% of respondents helped non-injectors with their first injection This was done either by directly injecting for them or by providing other forms of help including giving instructions such as estimate dosage, prepare injecting solution, set needle on vein, etc 59% of IDU reported injecting in front of non-injector, and 51% reported having talked about the perceived benefits of injecting

Determinants of HIT behaviors

In regression analysis, the three dependent variables (each of the HIT behaviors) were reversed as we want that IDU adopt “good” behaviors: Don’t Help smokers to inject for the first time (Don’t Help), Don’t Inject in the presence of smokers (Don’t Inject) and Don’t Take about the benefits of injecting to smokers (Don’t Talk) We list out here below all significant determinants of each behavior Don’t Help: four factors and “Injected in the presence of smokers in the last months” are identified as being significant determinants of not having helped another person inject for the first time in the past months The Odds Ratio score is listed for each determinants, together with the named OAM factor from the PSI behavior change framework

i My “ban chich” (group) doesn’t often talk with inhalers about injecting (Opportunity): OR = 1.70;

ii If a “ban nghien” asks me to help with their first injection, I can refuse (Ability): OR = 1.60; iii If an smoker who is suffering from drug hunger asks me to help them inject, I can refuse (Ability): OR = 2.88;

iv If I refuse to help someone inject for the first time, another IDU will not help them (Ability): OR = 1.91;

v Injected in the presence of smokers in the last months: OR = 0.60;

Don’t Inject: four factors and “Talked about the benefits of injecting to smokers in the last months” are significant determinants of not having injected in front of a smoker (but not IDU) in the past months

i My “ban chich” group does not often inject in the presence of inhalers in our group (Opportunity): OR = 1.90;

ii I have discouraged an smoker I know from starting to inject (Social support): OR = 0.74; iii Helping a “ban nghien” to start injecting may not increase our solidarity (Attitudes): OR = 1.35; iv If IDU don’t inject in the presence of inhalers, they will be less likely to switch to injecting (Attitudes): OR = 1.21;

v Talked about the benefits of injecting to inhalers in the last months: OR = 0.18;

Don’t Talk: three factors and “Injecting in front of smokers in the last months” are identified from the regression as determinants of not talking about the benefits of injecting with non-injectors, in the past months

i My “ban chich” (group) does not often talk with inhalers about injecting (Opportunity): OR = 1.67;

ii Once an inhaler is addicted to heroin, it is not evitable that they will eventually start injecting (Motivation): OR = 1.61;

iii IDU who use drugs in a group with inhalers are likely to encourage them to switch to injecting (Motivation): OR = 1.26;

iv Injecting in front of inhalers in the last months: OR = 0.20;

In addition to the determinants that are specific to each one of the three HIT behaviors, there are five factors that are common to all HIT behaviors These are:

14% 12%

21%

14%

3%

4% 4%

T

 not practicing needle sharing;  having less social contacts;

 having had a shorter duration of injecting;  having experienced drug hunger less; and

 not being asked or offered money to help somebody to inject Discussion

Findings from the behavior survey confirm the potential to reduce initiation into injecting drug use by targeting IDU and using the BTC model for HIT behaviors The data further confirms that there is a significant overlap and correlation between I, T and H

Qualitative research revealed an initiation process into injecting whereby existing IDU who talk about the benefits of injecting and who inject in the presence of heroin smokers (who are not yet IDU) are the people who are most likely to be offering help to first time injectors Help rarely comes from people outside of the social group or from people that are not known to them

Analysis of data from this survey reinforces this model Those who inject in the presence of non-injectors i.e in mixed groups of non-injectors and smokers, are more likely to talk about the benefits of injecting Similarly, those who inject in the presence of non-injectors are more likely to help a new injector with their first injection

The correlation between H, I, and T in this study were consistent with a similar study conducted in Canada in 20107 As the data confirms that a very high proportion of non-injectors (94%) are actively requesting for help with their first injection, the existing IDU have an active role in being able to reduce the extent of first time injecting The correlation between the HIT behaviors is summarized as below:

Program Implication

if intervention strategies are focused on IDU themselves and are designed in this way

However, BTC model can not stand alone It is built just as a supplement to other existing HIV preventive programs BTC should be easily integrated into national strategy and other related services for IDU such as Methadone treatment and Addiction Counseling Even BTC model can not be independent to other services; it should help to increase the total impact of the national system

References

1 Hunt N, Stillwell G, Taylor C, Griffiths P, (1998): Evaluation of a brief intervention to prevent initiation into injecting Drugs: Education, Prevention and Policy 1998, 5:185-194

2 PSI Central Asia (2006): Knowledge, Attitudes, and Practices of Injecting Drug Users related to the Initiation of Others into Injecting Drugs and Overdose in Tashkent and Bishkek, First Round

3 PSI Central Asia (2006): Injecting drug users in Bishkek, Kyrgyzstan and Tashkent, Uzbekistan: injecting histories, risky practices, and barriers to adopting behaviors less likely to transmit HIV

4 PSI Vietnam (2009): Break the cycle: peer-based formative research report among injecting drug users

5 PSI (2004) PSI Behavior Change Framework “Bubbles”: Proposed Revision Concept paper Stillwell G, Hunt N Taylor C & Griffiths P (1999): The modeling of injecting behavior and initiation into injecting; Addiction Research 7(5): 447-459

7 Strike Carol et al, Harm Reduction Conference Liverpool (2010): Targets for change – Injection initiation and modeling behaviors

DRUG USERS IN VIET NAM: HOW ARE THEY SEEN?

Authors:Daniel Khoa Pham, Timothy Moore, Nick Crofts*

* presenting author SUMMARY

The HIV epidemic in Vietnam is being driven to a very large extent by transmission of HIV among and from injecting drug users Efforts to stem this spread rely on effective interventions against risk behaviours, and treatment and prevention of drug use Implementation of effective interventions relies on public and policy support, based in turn on good understandings of drug use and drug users This presentation canvasses attitudes towards drug users and drug use in Vietnam by people involved in the formulation and implementation of policy, or by those affected by such policy Through interviews with a representative range of key informants, we discovered that in general public attitudes towards drug users are sympathetic, moreso where the informant has close experience of a drug user (e.g in the family); but that there are many myths still subscribed to by the majority There is a need for further public education to increase understanding of the nature of drugs, drug use, dependence and relationship with HIV transmission, if greater support is to be generated for widescale implementation of effective interventions

I BACKGROUND

Vietnam and Drugs Vietnam has a long connection with drug production and consumption, beginning in the early 19th century with British opium and continuing on into the 20th Century with the rise into prominence of heroin during the Vietnam War Reunification in 1975 however saw the implementation of restrictive drug policies throughout the country and drug consumption dropped dramatically

In the years following Doi Moi in 1986, Vietnam has made extraordinary socioeconomic progress in all sectors As with many emerging developing countries however, economic development comes with costs, and Vietnam has had to face a range of social problems, one of which is the re-emergence of illegal drugs – now driving the transmission of HIV (1)

Current Drug Situation in Vietnam

Drugs and drug use in Vietnam have seen three fundamental shifts in the last 50 years First is a staggering increase in the prevalence of drug use, mostly through the 1970s The second change is a shift in the demographics of drug users, especially in recent times to the ‘urbanisation of drug use’ (2) Males make up the overwhelming majority of drug users (1) In addition the average age has been decreasing; for those under 30 the prevalence has increased rapidly from 42% in 1995 to 70% in 2004 (3) The ethnic dimension of drug users has also shifted, from mostly ethnic minority groups in 1995 to mostly Viet/Kinh in 2001 (1) The third shift is the changing patterns of drug use over the past decade, particular with regards to types of drugs and modes of administration From the late 1990s onwards heroin has become the principal drug, particularly in urban centres, taking the place of opium; and the main method of use has switched from smoking to administration via injection (3) Latterly amphetamines are increasingly available and increasingly used also by injection

Vietnam’s Response To Date: Current Drug Policy

Vietnam currently has a zero tolerance stance on illicit drugs with the penalties for drug production, manufacturing and trafficking including capital punishment or life sentences However, actual use of drugs is not considered a crime but rather a sort of administrative offence; a ‘social evil’

Article 61 of the 1992 Vietnamese Constitution states that: ‘The State shall enact regulations on compulsory treatment of drug addiction and certain dangerous social disease’ (4) The main instrument used to carry out this edict is a network of compulsory drug treatment centres, known as ‘05/06 centres’ (5) Duration of compulsory treatment is usually one to two years and most residents at the centres are drug users admitted for compulsory treatment (86%) whilst the remaining 13% come voluntarily (6)

crucial in the centres given the high prevalence amongst drug users, is usually limited by a lack of adequate facilities and trained staff Relapse rates for drug users following compulsory drug treatment at the centres is as high, with national figures estimated as 70-80% and in some areas, greater than 90% (5,7) Re-incarceration for repeated illegal drug use is common This is mainly due to lack of resources to provide for comprehensive follow-up programs upon release Whilst efforts are made to aid residents in rehabilitating back into society especially through the provision of vocational training, due to the inadequacies of the training programs, less than 18% of released residents find regular employment (8)

II AUDIENCES AND METHODOLOGY Methodology

Aim: to contribute to an understanding of the perceptions of Vietnamese policy makers and implementers regarding drug use and drug users, so as to inform those who wish to address drug use in Vietnam (e.g by establishing harm reduction programs or more effective drug treatment etc.) to better understand the social environment in which they are working, and aid in tailoring their interventions more effectively

Objectives:

 To investigate how drug users are socially constructed in Vietnam and to identify and explore the rationales and motivations behind such constructions; and

 To promote further investigation of Vietnamese perceptions of drug use and drug users, and how and to what extent such perceptions influence policy and practices towards drug users

Literature Review Articles and documents relevant to the project were located using University of Melbourne SuperSearch search engines Search terms included: “Illegal/ Illicit Drug Use*”, “Drug abuse”, “addiction”, “substance related disorders”, “mandatory/compulsory drug treatment” and “Vietnam”

Study Design The project consisted of 17 in-depth, semi-structured interviews

Recruitment Participants were selected from organisations involved in drug policy formulation and implementation, recruited through professional contacts Organisations targeted included Government bodies with links with or interests in dealing with drug users (such as MOLISA, People's Committees, Youth Union, Women's Union, and Community level social workers/volunteers), some of the various policing services, domestic and international NGOs and UN organisations

Data Collection Audio recordings were made of interviews with the participant’s permission and were then transcribed into English following discussion between the researcher and the interpreter

In-depth Interviews Participants were asked their opinions on drug use and drug users in Vietnam, current drug policies and what further actions they believe is required in order to address the issue Open-ended questions and topics were phrased to allow participants not to only act as subjects offering their own viewpoints, but to also act as key informants, venturing their informed opinions on what other groups involved in drug policy formulation/implementation may think on the issues covered and the reasons for these perceptions

Data Analysis Thematic analysis of the English transcripts of the interviews was conducted with key themes being identified and categorised Relevant quotes and observations were then identified and sorted into the designated categories and themes

III RESEARCH OUTPUT

Findings The findings of the research, in terms of common themes and quotes to illustrate these themes, will be presented under the following headings:

Understanding of Drugs Understanding of Dependency Perceptions of Drug Use The ‘Average’ Drug User Drug User Character Rationale for Initial Drug Use Knowledge and Opinions on Policy on Drugs

Policy Towards Drug Users Understanding of Harm Reduction Knowledge and Opinions on Harm Reduction

Opinion of Harm Reduction Programs

Examples of key themes, quotes and findings:

The types of ‘drugs’ most frequently recognised included heroin; few mentioned pharmaceutical substances In addition, although alcohol and nicotine were recognised as drugs by more educated participants, these substances are not thought of as drugs by the general public

 There was unanimous agreement that drugs were harmful and dangerous, causing the degradation of individuals physically, mentally, emotionally and socially

 There was a general consensus that it is absolutely necessary to control drugs because of all the evils they cause However, it was widely recognised that totally controlling or even eradicating drugs was an impossible task

 Universal amongst the participants was the belief that most drug users held a desire to quit drugs However, all participants recognised that being able to quit drugs was very difficult to achieve and maintain

 Drug dependency was recognised as a multi-factorial issue which requires attention to not onlu its physical , but also its associated mental and psychological manifestations in order to be effective The thinking of general public, by contrast was said to be largely devoid of this perspective

“[The public believe that]once you’re an addict, you use it because of your moral weakness and they don't understand it is a condition They don't understand the complexity of dependency, physically, psychologically and socially They also don't understand the interaction between the drug environment and the individual This triangle is quite complex, difficult for drug users” NGO representative

 Very few participants openly opined that drug users were bad people yet a proportion of interviewees held the view that drug users are law breakers and even criminals However, it was often stressed that drug users were entirely normal people, perhaps even good people, whose behaviour only became misguided or ‘bad’ when they are in the grips of their dependency

“I don’t think that drug users are bad people because even the people who not use drugs still commit social evils And the people who use drugs, if they have sufficient drug supply, and they are not caught or sent to any centre, can still contribute to society, still work and other things as well”. NGO worker

III DISCUSSION

Whilst respondents described society’s view of drug users as generally negative, it is suggested this is not an entrenched viewpoint Instead, this point of view is based on a series of assumptions which are more informed by cultural ideology than by anything else and thus open to change, provided there is sufficient information exists to dispute current conceptions Even amongst informed members of society there is still a belief that the best method of treatment was the removal of drug users from settings where drugs were readily available; a belief that lends its support to the current use of the mandatory treatment centres In addition, opinions on the management of drug users in Vietnam were often laced with subtexts suggested there were other issues beyond the health of individual drug users which play an equal or perhaps even greater part in the motivations behind current policy Whilst public health was often mentioned as a motivation, other issues like national security and economic concerns were also emphasised Consequently, attempts to try and advocate alternatives to the 05/06 centres may be hindered if they are not seen as adequately addressing this concern of security or other deeper agendas

V RECOMMENDATIONS

In this paper, a range of perspectives were found amongst local policy makers and implementers regarding drugs and drug users in Vietnam, reflecting the diversity of the respondents in the study Overall, this sample population was more sympathetic and understanding towards drug users compared to the more negative opinions perceived to be held by Vietnamese society

practice treatment, and allow drug users to regain their rights as citizens of the nation and their entitlement to human dignity

REFERENCES

1 Nguyen VT, Scannapieco M Drug abuse in Vietnam: a critical review of the literature and implications for future research. Addiction

2008;103:535-2 Rapin AJ, Dao HK, Dong ND, Eyres J, Tran VC, Higgs P, et al Ethnic Minorities, Drug Use and Harm in the Highlands of Northern Vietnam: A contextual analysis of the situation in six communes from Son La, Lai Chua and Lao Cai. Hanoi: UNODC; 2005.X3 United Nations Office on Drugs and Crime (UNODC) Country Office Vietnam Vietnam Country Profile 2005 Hanoi; 2005

4 The Constitution of Viet Nam. 1992

5 World Health Organization (WHO) Assessment of compulsory treatment of people who use drugs in Cambodia, China, Malaysia and Viet Nam: An application of selected human rights principles. 2009

6 Standing Office for Drugs Control (SODC), Ministry of Public Security et al Project G22: Reduction of HIV infection risk due to drug abuse in Vietnam. 2005

7 Ministry of Labor, Invalids and Social Affairs (MOLISA), Department of Social Evil Prevention

Assessment of effectiveness of treatment for drug addiction and preventive measures, care and treatment for HIV/AIDS at Centers for Treatment – Education – Social labor in Vietnam. 2009

METHADONE MAINTENANCE THERAPY: LESSONS FROM CHINA

Author: John Leigh Summary

At the end of 2009 China had 112,800 patients currently on MMT at 680 clinics across 27 provinces This is a major achievement considering MMT was only approved for national roll-out in July 2006 It is already one of the largest MMT programmes in the world and continues to expand rapidly Studies show that MMT in China is strongly associated with reduction in high-risk behaviours and lower crime rates As part of a more comprehensive harm reduction approach that also includes NSPs and condom distribution, MMT has been instrumental in containing HIV transmission among IDUs in China This paper looks into the factors that have contributed to this success and the challenges China still needs to address if it is to completely reverse the HIV epidemic among IDUs

I Background

China has at least million IDUs with an average HIV prevalence of between 6% and 7% (general population prevalence = 0.057%) Until 2006 IDUs were the major route of HIV transmission and in 2009 still accounted for 32.3% of transmission according to official figures While 44.3% of 2009 transmission was attributed to heterosexual sex (and 14.7% to homosexual sex), it is suspected that a significant proportion of heterosexual transmission has its origins in the IDU community China started piloting harm reduction programmes in 1999 when national HIV prevalence among IDUs was estimated at around 9%, with pockets in excess of 50% The first methadone trials took place in 2004

II Major content

A Brief history of MMT as a key component of harm reduction in China

China’s HIV epidemic was initially detected in 1989 among IDUs in Yunnan Province close to the Burmese border and has primarily been driven by IDUs The initial response was of containment – isolate offenders in compulsory detoxification centres – but, like elsewhere in the world, this has proved ineffective at controlling both drug use and HIV transmission NSPs were officially introduced in 2001 as ‘needle social marketing’ to avoid the appearance of condoning drug use (Needle exchange programmes are still not officially sanctioned by the Ministry of Public Security.) MMT was piloted at eight sites in 2004 and, based on the positive results, scale-up started later the same year and nationwide roll-out received the green light in 2006 By the end of 2007 MMT was being provided through 397 clinics in 22 provinces, with a plan to increase the number to 1,500 by the end of 2008 In reality, the roll-out has been somewhat slower, but impressive nonetheless

Key factors influencing this rapid adoption of MMT have been identified as: political leadership from the top of Government, with President Hu Jintao and Premier Wen Jiabao playing crucial roles; dynamic technical leadership from the National Centre of STD/AIDS Control and Prevention; internationally funded projects bringing in international best practices; the role of the national media; and the 2003 SARS epidemic which served as a wake-up call regarding China’s vulnerability to infectious diseases

B Harm reduction versus traditional approaches: a continuing tension

As in other countries, there are multiple perspectives and multiple objectives in China when it comes to dealing with the interaction between drug use and HIV From the public health perspective there is no controversy about MMT It has been well proven to reduce HIV transmission by reducing injecting drug use and thereby protects not only the health of the individual patients but also of society as a whole

in China the prevalent approach is to what brings results, regardless of the ideology MMT has been seen to bring down crime, so it is widely promoted However, harm reduction programmes are still run in parallel with more traditional approaches and the continuing tension between the two is preventing more rapid progress in both drug control and HIV prevention

There is also an economic perspective This looks both at the economic costs to society of drug use and of HIV/AIDS and at the cost-effectiveness of the various interventions One of the factors leading the Chinese Government to adopt harm reduction approaches in general was the cost-effectiveness argument MMT was piloted in a few sites and found to deliver results while still being affordable and was then given the green light for rapid scale-up But paradoxically, large numbers of drug users continue to be locked up in compulsory detoxification centres, despite the fact that these have been shown actually to increase high-risk behaviours as well as being extremely expensive to run

Finally, there is the human rights perspective With China’s increasing opening up, with its associated press freedoms and ever more vocal civil society, this is becoming a more prominent issue However, it was not a major factor in the original design of the MMT programme

C MMT cannot be seen in isolation from other interventions

From an epidemiological perspective, MMT is only a partial solution to HIV control among IDUs It is effective in reducing needle-use However, a comprehensive approach needs to three things: (1) reduce injecting drug use, (2) reduce unsafe injecting practices among those who continue to inject, and (3) reduce the probability of HIV infection through unsafe practices MMT, when combined with appropriate psycho-social support, is effective in achieving the first of these NSPs, combined with targeted Behaviour Change Communication programmes, are effective in achieving the second To achieve the third, IDUs must have access to ART programmes to reduce viral load among those already infected China has good examples of all these interventions being available together, but these are exemplary sites Fully integrated comprehensive services are not yet available in many areas From a psycho-social perspective, MMT is only effective as part of a holistic approach that addresses the underlying reasons for drug dependence It should not be seen merely as a physiological substitution of one addictive opiate for another MMT clinics in China that provide comprehensive counselling services and are well integrated with local communities have been shown to be far more effective than those that simply provide methadone

From a political/administrative perspective there are still some significant challenges faced by China’s MMT programme Compulsory registration of patients with Public Security and compulsory urine tests are significant deterrents to increasing coverage The absence of legal sanction for NSPs further limits patient numbers through lack of integration of the two programmes, although there are exceptions Non-availability of MMT in closed environments is a further problem, although recently the Ministry of Justice has expressed openness about the possibility of piloting MMT for some inmates

III Results

China has developed a high quality MMT programme and rapidly scaled it up to an extent that is unprecedented anywhere This is a successful story of collaboration between law enforcement agencies and the public health authorities The impact on public security is evident, with police officers throughout the country being impressed by the significant reduction in crime rates in areas where MMT clinics are operating Furthermore, surveillance data show that the HIV epidemic is being contained successfully among the IDU community National HIV incidence levels among IDUs never reached the levels they have reached in neighbouring Southeast Asian or Central Asian countries and are now showing modest declines in most places This demonstrates the effectiveness of harm reduction approaches, as without these the incidence rate among the very large IDU population would undoubtedly have continued to rise

compulsory detoxification is a major driver of high-risk and anti-social behaviours Secondly, the MMT programme is quite centralized, making access prohibitively difficult for IDUs in small towns and rural areas However, some provinces, notably Yunnan, have started to decentralize MMT services below the county level and this is beginning to show results

There are also some structural issues regarding the management of MMT clinics that the Chinese Government is grappling with Medical staff posted to MMT clinics are frustrated by the boring and sometimes risky work and the perceived stagnation of their professional career development Staff also complain of long working hours, and yet the clinics that are able to stay open longer are consistently more successful in attracting more patients On the other hand, there is a shortage of staff that are adequately trained in the necessary counselling skills

IV Lessons Learned

1 China has effectively contained the spread of HIV among IDUs by scaling up harm reduction approaches that are jointly endorsed and managed by health authorities and law enforcement bodies This has been a pragmatic approach, with the local authorities in the most successful areas prepared to take a liberal approach to law enforcement with a view to achieving better public health outcomes As positive results in crime prevention have also become evident, this has encouraged more support for harm reduction approaches in contrast to traditional punitive approaches

2 New legislation has started to decriminalize drug addiction by categorizing it as a chronic disease that requires treatment Despite the continuance of some harsh and punitive legal provisions, this recategorization has started to bring about an important attitudinal change among governmental agencies and among the general public

3 Several studies of the development and roll-out of China’s MMT programme have identified some key factors which improve the effectiveness of MMT:

a Community-based approaches linked with the provision of professional counselling b Close integration with complementary NSP and ART programmes

c Flexibility of methadone dosage, supervised by a qualified medical practitioner, with the ability to give quite high doses if necessary

d Good physical access in terms of both time and place Clinics need to have long opening hours and be within 30 minutes travelling distance of clients Mobile clinics can be an option in some locations

4 For China to move from containing the epidemic among IDUs to reversing it, some further developments are called for:

a Drastically reduce the use of compulsory detoxification and introduce MMT within the detention centres Compulsory centres should only be a last resort when patients exhibit continuing high levels of injecting drug use and anti-social or criminal behaviour even after extensive community-based approaches and MMT

b MMT services should be further decentralized, integrating them with clinical and primary care services that are already available at more decentralized levels

c Formally legalize NSPs and ensure that MMT and NSPs can be fully integrated under joint management of the health authorities and public security agencies

d Extend the provision of harm reduction services, including MMT, by carefully screened non-state providers These could include, for example, international NGOs and private medical practices

References (in chronological order)

Liu, H., Grusky, O., Zhu, Y & Li, X., 2006, Do drug users in China who frequently receive detoxification treatment change their risky drug use practices and sexual behaviour? Drug and Alcohol Dependence Vol.84: 114-121

Sullivan, S & Wu, Z., 2007, Rapid scale-up of harm reduction in China International Journal of Drug Policy Vol.18: upload.123doc.net-128

Wu, Z., Sullivan, S., Wang, Y., Rotheram-Borus, MJ & Detels, R., 2007, Evolution of China’s response to HIV/AIDS Lancet Vol.369: 679-689

Pang, L., Hao, Y., Mi, G., Wang, C., Luo, W., Rou, K., Li, J & Wu, Z., 2007, Effectiveness of first eight methadone maintenance treatment clinics in China AIDS Vol.21: S103-S107

& Shao, Y., 2008, Impact of methadone on drug use and risky sex in China Journal of Substance Abuse Treatment Vol.34: 391-397

Lau, JTF., Zhang, L., Zhang, Y., Wang, N., Lau, M., Tsui, HY., Zhang, J & Cheng, F., 2008, Changes in the prevalence of HIV-related behaviours and perceptions among 1832 injecting drug users in Sichuan, China Sexually Transmitted Diseases Vol.35: 325-335

Che, Y., Assanangkornchai, S., McNeil, E., Chongsuvivatwong, V., Li, J., Geater, A & You, J., 2010, Predictors of early dropout in methadone maintenance treatment program in Yunnan province, China Drug and Alcohol Review Vol.29: 263-270

Lin, C., Wu, Z., Rou, K., Yin, W., Wang, C., Shoptaw, S & Detels, R., 2010, Structural-level factors affecting implementation of the methadone maintenance therapy program in China Journal of Substance Abuse Treatment Vol.38: 119-127

Liu, Y., Liang, J., Zhao, C & Zhou, W., 2010, Looking for a solution for drug addiction in China: exploring the challenges and opportunities in the way of China’s new drug control law International Journal of Drug Policy Vol.21: 149-154

Larney, S & Dolan, K., 2010, Compulsory detoxification is a major challenge to harm reduction in China International Journal of Drug Policy Vol.21: 165-166

Lin, C., Wu, Z., Rou, K., Pang, L., Cao, X., Shoptaw, S & Detels, R., 2010, Challenges in providing services in methadone maintenance therapy clinics in China: service providers’ perceptions

International Journal of Drug Policy Vol.21: 173-178

ENGAGING WITH POLICE IN PREVENTION OF HIV AMONG AND FROM INJECTING DRUG USERS

Authors: Nick Crofts* for the Law Enforcement and Harm Reduction project at the Nossal

Institute (LEHRN)+

* presenting author Summary

Injecting of illicit drugs is a major driver of HIV epidemics across South East Asia A predominant response to illicit drug use has been intensive enforcement of prohibition policies and enforced abstinence approaches, with police in the front line of enforcement of these policies This approach is often in conflict with effective approaches to control of HIV epidemics, and police are often seen as ‘the enemy’ of harm reduction The LEHRN project works closely with police in Viet Nam, Cambodia and Laos to discover how to build effective partnerships between law enforcement and harm reduction, to improve outcomes for society, the community and the drug users – especially in relation to HIV control We will present here lessons learned to date about how these partnerships can be made more effective

Background

Injecting drug use (IDU) has been spreading in much of the world over the last decades In many countries of South-East Asia it has been increasing numerically, expanding geographically, and penetrating many social strata, driven by economic development and globalization among other things This has set the scene for epidemics of HIV among IDUs and from them to their sexual partners, especially where there is a crossover of IDU and sex work This leads to HIV epidemics which mimic heterosexually-driven epidemics; it has also set the scene for repressive and often brutal social responses to IDU and drug users

A common response to illicit drug use has been to conduct intensive street level ‘crackdowns’ by law enforcement agencies, resulting in lengthy, and lengthening, internment in compulsory detention centres These camps often have few resources to drug treatment, and often are not very effective at rehabilitation and reintegration into society High risk activities for transmission of such as drug use, needle sharing and unprotected sex can occur amongst detainees (e.g Amon 2009, bin Ali 2009, Pearshouse 2009)

Police are the front line of these responses Police confront the drug user, arrest, and send them to compulsory treatment centres or other administrative detention (e.g Fairbairn et al, 2009) For this reason, many supporters of harm reduction see police as one of the barriers to effective HIV control; and it is often the case that police not recognize their role in harm reduction – usually because there has been little attempt to engage or inform them, to form working partnerships

Everyone who runs a harm reduction program knows that police can be your worst enemy or your best friend Australia has seen the effectiveness of the police and harm reduction partnership, at the senior policy level, and at the local, community level Where this happens in Asia, as is increasingly the case, similar effective responses are being generated Yet while this is increasingly the case, it is still only in a small minority of communities

Major content

The Law Enforcement and Harm Reduction at the Nossal Institute (LEHRN) Project is investigating the relationship between law enforcement and harm reduction in Viet Nam, Cambodia and Laos, with partner researchers from those countries and Australia Key principles from which the LEHRN Project takes its starting point include:

 the law enforcement sector is key to the success of attempts to control the HIV epidemic among and from illicit drug users, and

 law enforcement can be a major barrier or a major ally in the fight against HIV: the harm reduction community must engage effectively with law enforcement if there is to be effective change

As part of this project, LEHRN holds regular seminars bringing researchers, harm reduction programs and police together, with government, NGOs and INGOs, UN/WHO and academia, to investigate effective partnerships Such a seminar, entitled “Law Enforcement and Harm Reduction: Effective Partnerships” was held in Phnom Penh on 24th February, 2010 The aim was to better understand the importance of the harm

The LEHRN Project is based on the appreciation that while the negative impact of law enforcement on illicit drug use and drug users, in terms of HIV prevention, is well described, we have poor understanding of how harm reduction philosophy and approaches as practised by programs dealing with drug users impact the policy and practice of law enforcement Do we know how to engage law enforcement, to find common ground and common goals with harm reduction, to build effective partnerships? In the fight against HIV among and from illicit drug users, and against other harms to the individuals, their families and the wider communities of which they are a part, we need better knowledge of how to build these positive relationships The LEHRN Project is therefore building the capacity of public health researchers in Laos, Cambodia and Viet Nam to produce evidence on the impact of harm reduction programs on law enforcement policy and practice, to bring us closer to completing the circle of understanding, and enable more positive policy settings This includes the facilitation of seminars which cover:

 reviews of the situation regarding illicit drugs and the HIV epidemic in South-East Asian countries and regionally;

 the perspective of these situations from the law enforcement point of view;  responses at regional and national level; and

 reports and updates from the LEHRN Project’s current research (to be presented at this conference as a Satellite Session)

A major issue highlighted during the seminar was that harm reduction had generally failed to present evidence that was compelling in terms of the benefits for police Advocacy with law enforcement by harm reductionists is almost always couched in health terms, seen as either foreign and/or irrelevant by law enforcement – “it’s not our job, why should we care?” In advocacy terms, recasting the approach to examine and present “what’s in it for them (law enforcement)?” is a far more effective approach It can stand as an exemplar of how harm reduction gains support from community groups, businesses and other influential players If you can frame the evidence in a way that is compelling for police to support harm reduction – if they see it as being in their own self-interest – they will drive advocacy with these other groups Self-interest comes in many forms – perhaps the simplest example being occupational health and safety for police: needle and syringe programs substantially reduce the risk of needlestick injuries to police, as well as to the rest of the community; and also substantially reduce the chance that a needlestick injury, if it happens, will be from someone infectious with a bloodborne virus But there is much more in relation to self-interest for police in a harm reduction approach to policing illicit drug use

Roundtable discussions are held with each seminar to distil the lessons learned about the importance of building and strengthening the law enforcement and harm reduction partnership, share experience and research to date and to review information presented at the seminar and other experience that participants had gained from working with law enforcement

Results

Major points highlighted by the Phnom Penh roundtable discussion include:

1 The involvement of law enforcement is critical to the success of harm reduction programs at all levels – regional, national and local

2 There is a pressing need for law enforcement agencies and authorities to share ownership of harm reduction

3 Police must be engaged early by harm reduction programs; not as a subsidiary but as a core partner There is a need to document the experiences of law enforcement and harm reduction working together in the region, at all levels

5 Involvement of law enforcement at local level must be through effective community partnerships based on mutual understanding and respect, and should include local communities, local police authorities and other partners

6 There need to be multi-sectoral structures among all key agencies involved at all levels, so that working relationships can be established and maintained

7 To ensure police and others in the law enforcement sector are enabled to fulfill a harm reduction mission and have the capacity to be effective partners, they need adequate resourcing

8 Harm reduction activities must be integrated into police planning, and show congruency with other government department plans

10 Solutions must be practical and be seen to be of worth by police – police responses and responsibilities in the partnership must be operationalised

Lessons learned

Recognition of the adverse role of law enforcement in illicit drugs issues, of its contribution to increasing HIV risks and vulnerabilities, must be matched by recognition of the legitimate role police and other law enforcement agencies have in relation to public health Working with police to change cultures and enhance their ability to work collaboratively and community-wide to protect all members of a society from preventable ills is critical to progress in stopping HIV epidemics among and from IDUs, and therefore in most Asian countries But this work needs recognition from governments, donors and multilateral agencies that there is a need to urgently and massively boost other services for those at risk, especially illicit drug users and their families – primary health care, effective community-based drug treatment, and mental health services being among the most pressing

At this stage of the HIV epidemic, after 25 years’ experience in Asia, some lessons have been learnt:  HIV epidemics in Asia will not be stopped until transmission is stopped among and from people who inject drugs;

 HIV transmission will not be stopped among and from these people until repressive uni-dimensional law enforcement approaches give way to rational drug policies, with provision of accessible, humane and effective community-based drug treatment programs for all who need them; and

 The underlying lack of opportunity for meaningful lives must be addressed at the community level in programs of human rights-based social and economic development

This is, above all, a fight for human rights for the most marginalized of people; and as harm reductionists, our slogan is pragmatism – and what works in this fight, we are increasingly learning, is engagement with ALL members of society, including especially affected communities and law enforcement

References

Amon J Health and human rights concerns of drug users in detention in Guangxi Province, China Harm Reduction 2009, Bangkok 20-23 April; Abstract 821, Session C3

bin Ali US “Break you down to build you up”: the Malaysian experience Harm Reduction 2009, Bangkok 20-23 April; Abstract 510, Session M2

Fairbairn N, Kaplan K, Hayashi K, Suwannawong P, Lai C, Wood E, Kerr T Reports of evidence planting by police among a community-based sample of injection drug users in Bangkok, Thailand BMC International Health and Human Rights 2009, 9:24

Pearshouse R An overview of Thailand’s compulsory drug rehabilitation Harm Reduction 2009, Bangkok 20-23 April; Abstract 836, Session M2

+The LEHRN Partnership:

University of Health Sciences, Vientiane, Lao PDR: Vanphanom Sychareun, Sysavanh Phommachanh, Vathsana Somphet - Faculty of Postgraduate Studies

National Institute for Public Health, Phnom Penh, Cambodia: Chheng Kannarath, Leang Supheap, Thou Chourn

Institute for Social Development Studies, Ha Noi, Viet Nam: Khuat Thu Hong, Bui Thu Huong, Nguyen Thi Van Anh

The Nossal Institute for Global Health, University of Melbourne, Australia: Timothy Moore, Natalie Stephens, Greg Denham, Nick Crofts, Melissa Jardine

 The Law Enforcement and Harm Reduction Network website: www.leahrn.org

 The LEHRN website:

HIV/AIDS RELATED RISK BEHAVIORS AMONG

MALE INJECTING DRUG USERS (IDUs) IN SON LA PROVINCE, VIETNAM

Bui Thu Trang, Phan Thi Thu Huong, Nguyen Van Ky, Bui Hoang Duc, Nguyen Viet Nga

ABSTRACT

The objective of this study was to examine the risk behaviors and their determinants among Male Injecting Drug Users (IDUs), especially focusing on the effect of an HIV/AIDS intervention program on the risk behaviors of IDUs in Son La province, Vietnam This study used the data from a cross-sectional survey of 502 male IDUs conducted by the Vietnam HIV/AIDS prevention project of the World Bank

Results illustrated that 27.5% of IDUs reported sharing needles and syringes 15.9% of the IDUs reported having sex with female sex workers and 30% of them used condom consistently 56.4% of IDUs received clean needles/syringes and 33.1% of IDUs received condoms from the intervention program IDUs with access to the program were 71% less likely to share needles/syringes than those without access (p<0.01) Besides, IDUs receiving free condoms were 17.3% times more likely to use condoms with their wives/girlfriends

By using logistic regression, it was demonstrated that the intervention program in Son La reduced the amount of these HIV/AIDS related risk behaviors of IDUs The HIV/AIDS intervention program should be increased to guarantee the availability and accessibility of condoms, clean syringe and needle distribution to IDUs

CHAPTER I: INTRODUCTION

The transmission and HIV prevalence among IDUs is a major concern of HIV/AIDS prevention program in Vietnam Injecting drug use is a key mode of HIV transmission, accounting for 56% of new HIV cases in 2008 (MOH, 2009) 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 Since the needles syringes exchange program had implemented on wide scope in 2005, the HIV transmission trend had began to decline among IDUs over time, in 2008, HIV prevalence was down at 20% (MOH, 2009)

The Law on HIV/AIDS and the Decree 108/2007 ND-CP of Vietnamese government has set up a solid foundation for harm reduction activities in Viet Nam The harm-reduction program has been strongly supported by international partners (UNGASS 2006) The program has mainly focused on providing information, condoms and needles/syringes, and referral to VCT services targeting injecting drug users, female sex workers, and mobile populations However, interventions targeting mobile populations and interventions in closed settings are still limited (UNGASS 2006) Migrants and mobile populations are included in both the National Strategy and Law; however there is no specified strategy or program to ensure their access to prevention, treatment and care and support services as yet (UNGASS 2006)

Son La is a mountain province in East-North Vietnam with a population of 1.080.641 people, divided into 12 ethnic groups, 82% of Son La population are minority ethnic Son La is located near the border with Lao, China and the National road No.6 which directly links to Ha Noi capital, therefore the area has become one of most seriously hotspots for drug trafficking in the North As reported, by 31/3/2009, among 16.592 IDUs identified in 201 sub-districts in Son La, there were 6.271 cases were infected with HIV, 1.095 cases were diagnostic as AIDS and 655 deaths caused by AIDS The Ministry of Health estimated that HIV spreads quickly among IDUs in Son La province (22% of IDUs are infected with HIV) and occurs mainly among people aged 20-30 years old

province from 2005 to 2011 This research will glean information for raising awareness and understanding of high-risk behaviors among IDUs as a public health issue This research is essential as it will examine whether HIV/AIDS intervention program has any impact on IDU’s risk behaviors after years of implementation It is important to recognize that potential intervention needs to be responsive to help describe the risk factors in which the unsafe behavior occurred The result of this analysis might have a profound impact on the nature of future initiatives and intervention programming in Son La

CHAPTER III: RESEARCH METHODOLOGY

1 Source of data: This study used the secondary data from the KABP (Knowledge, Attitudes, Belief and Practice) cross sectional survey of 502 male IDUs on their risk behaviors and HIV status to support an evaluation of HIV/AIDS prevention project funded by World Bank The survey was conducted from October to December 2009 in districts of Son La province including Son La downtown, Moc Chau, Mai Son, Thuan Chau, Muong La

2 Sampling and study population: 502 IDUs included in this survey were selected to interview by snowball sampling method based on the peer educators of project Those were 15 years of age or older, residents of the study area, and committed drug injection at least one time during the months from the previous to survey time The local health care workers in charge of the HIV program at commune health centers then made a contact to invite them to participate in the study

CHAPTER IV: RESEARCH FINDINGS

Among 502 IDUs participated in the research, 6.8% of them are illiterate, 24.3% of them have primary school level and the major part has secondary school level (40.6%) More than a half of them are farmers (59.1%) Their average age is 32.78 with the youngest is 16 and the oldest is 67 76.5% of them those answered correctly or more out of 10 questions on HIV/AIDS are considered as having good knowledge on HIV/AIDS in this research According to the characteristics of drug injection behaviors, 44.6% of respondents had been injecting for years or longer 39.8% of those IDUs reported injecting drug twice or more per day

The proportion of IDUs who reported sharing needles and syringes in the last month is 27.5% During the last 12 months before the research, there are 15.9% of respondents reported having sex with FSWs or un-regular partners Among those who had sex with FSWs or un-regular partners (n=80), there is only 30% reported using condom all the times The proportion of using condom with wives or girlfriends at the last sexual intercourse is 32.8%

Regarding to the accessibility of intervention program, the result showed that 56.4% of IDUs reported receiving clean needles/syringes during the last six month, while only 33.1% of them reported receiving condom from the program There are 22.1% of respondents had gone to VCT rooms and had HIV test as well as receiving counseling from the counselors 72.9% of those IDUs also reported receiving counseling on HIV/AIDS from different people (peer educators, health workers, friends…) Base on the level of educational level, the data showed that the highest educational level (high school or higher) have the highest proportion of sharing needles/syringes (33.1%) The primary level group’s proportion of using condom with FSWs or un-regular partners is lowest (10%) while the secondary level group has highest condom use with wives or girlfriends at the last intercourse (35.5%) Regarding occupation groups, there is not much difference between farmer group and other group in sharing needles (26.1% versus 24.7%), use condom with FSWs (29.7% versus 26.3%) as well as with wives or girlfriends (66.0% versus 65.6%) Considering the age groups, the group under 25 years old sharing needled much more than group above 35 years old (33.3% versus 20.9%), but the proportion of using condom with FSWs or un-regular partners of group under 25 is higher than group above 35 also (33.3 versus 22.7)

The group injecting twice or more per day had the highest proportion of sharing needles (37%) The data showed that the group injecting less than time per day had the lowest condom using with FSWs or un-regular partners (26.1%) 25.5% of IDUs who has good knowledge on HIV/AIDS reported sharing needles/syringes while 35.5% of those who has poor HIV/AIDS knowledge shared needles Those have good HIV knowledge would use condom with FSW rather than those who have poor knowledge on HIV (33.9% versus 18.8%)

proportion of IDUs who had sex with FSWs or un-regular partners use condom consistently is 30% This is a high risk combination behavior which makes the HIV transmission become more serious

The result indicated that IDUs who received needles and syringes from program during the last months have proportion of sharing needles likely less than who did not (15.2% versus 43.3%)

50% of those who received condom from the intervention program use condom consistently with FSWs or non-regular partners while there is only 13.6% of those who did not received free condom reported use condom In addition, from the data on this table, it showed that 70.1% of IDUs who received free condoms would use it with wives or girlfriends at the last sex intercourse and only 13.1% of those who did not received free condom used it with wives or girlfriends

For IDUs who received counseling on HIV/AIDS, 35.1% of them used condoms consistently with FSWs/un-regular partners and 36.4% of them use condoms with wives/girlfriends; while IDUs who did not received counseling

The proportions use condom consistently with FSWs and at the last sex intercourse with wives of IDUs who have ever had HIV test with counseling at VCT rooms are 33.3% and 46.3% respectively While these proportions of IDUs who have never had HIV test at VCT rooms are 23.2% and 29% respectively

4.1 Binary logistic regression analysis on sharing needles/syringes behavior

Among control variables, age, having sex with FSWs/un-regular partners have significant associations with the sharing needles/syringes behaviors IDUs who are 35 years old and older are 50% less likely to share needles/syringes than those who are under 25 years old (p<0.05) Sexual intercourse with FSWs/un-regular partners increased probability of sharing needles of IDUs 2.24 times (p<0.05)

After complement with HIV/AIDS intervention program variables as: receiving clean needles/syringes, receiving counseling on HIV/AIDS, taking HIV test with counseling The result shows that IDUs who received clean needles/syringes from intervention program are 70% less likely to share needles/syringes than those who did not (p<0.001) The data does not indicate that receiving counseling on HIV/AIDS and taking HIV test have significant effect on needle sharing behavior

Age and having sex with FSWs have significant effect on needle sharing behavior (p<0.05) and the intervention program variables have a significant effect on increasing the prevention behavior (not sharing needles/syringes) of IDUs

4.2 Binary logistic regression analysis on condom use with FSWs or un-regular partners of IDUs

Among control variables such as: education, occupation, age, HIV/AIDS knowledge, duration and frequency of injection and needles sharing behavior, there are no variables those have significant effects on condom use with FSWs/un-regular partners of IDUs Even after adding intervention program variables into the model to examine, there is still no any significant effect on condom use with FSWs/un-regular partners of IDUs

4.3 Binary logistic regression analysis on condom use with wives or girlfriends of IDUs

There is a big difference after adding intervention program variables including receiving free condom, receiving HIV/AIDS counseling and taking HIV test into the model to examine Among all variables, there is only receiving free condom from intervention program variable has significant effect on condom use with wives/girlfriends behavior The result reveals that IDUs who received free condom from program are 17.3 times more likely to use condom with wives/girlfriends than those who did not

CHAPTER V DISCUSSION

HIV/AIDS prevention behaviors of IDUs regarding the accessibility of intervention program were examined in this study with following findings

might indicate that needles and syringes are not easily obtained in the research sites

Otherwise, the majority (72.9%) IDUs reported receiving counseling (from peer educators, friends, health workers…) and 22.1% of them reported sharing needles/syringes, 35.1% of them reported use condom consistently with FSWs/non-regular partners, 36.4 of them reported use condom with wives/girlfriends at the last sexual intercourse However, in six binary regression models, there is no evidence confirm that receiving counseling on HIV/AIDS has significant effect on HIV/AIDS prevention behaviors of IDUs Therefore, not only the quantity but also the quality of counseling on HIV/AIDS for IDUs should be more concerned in the intervention program and in researches

This study also found that IDUs who have had sex with FSWs/un-regular partners are 2.16 times more likely sharing needles than those who did not (p<0.05), and combining with the proportion of not use condom consistently with FSWs/un-regular partners of IDUs is high In addition, receiving condom from program did not have significant effect on condom use with FSWs of IDUs These results warns a high risk of HIV transmission between IDUs group and FSWs group which makes the HIV epidemic become more serious and complicated

In other side, receiving condoms from program has a significant effect on condom use with wives/girlfriends of IDUs Accessing free condom from program increases the probability of using condom with wives/girlfriends 17.3 times among IDUs who received condom as compared to those who did not (p<0.001)

Regarding sharing needles and syringes, this research shows that IDUs who are 35 years old and above are 64% less likely to share needles and syringes than those who are under 25 years old (p<0.05) This result suggests that the youngest IDU group in Son La should be more concerned in intervention program with appropriate accessibility An important result in this study is receiving clean needles/syringes from intervention program decreases the proportion of sharing needles/syringes of IDUs by 71%, this proportion is higher in comparing with the study in Thanh Hoa in which the proportion of sharing needles/syringes of IDUs reducing by 52% by the effect of receiving needles/syringes from intervention program (Son., 2009)

This study’s results also indicate that IDUs who received free needles and syringes are less likely to share needles/syringes than those who did not receive needles and syringes Also, those who received free condoms are more likely to use them with their wives and girlfriends but there is not a significant result confirm that receiving condom increasing their condom use with FSWs or non-regular partners

CHAPTER V: CONCLUSION AND RECOMMENDATION A Conclusion

Our study found that there are 27.5% of IDUs in Son La reported sharing needles during the last month prior to the survey There are 56.4% of IDUs received clean needles from intervention program The needle and syringe sharing was more common among IDUs who are under 25 years old (OR 2.7, p<0.05), and among IDUs who have had sex with FSWs/un-regular partners (OR 2.16, p<0.05) IDUs who received needles/syringes from intervention program are 71% less likely to share needles/syringes than who did not (p<0.01)

Regarding the HIV/AIDS prevention on sexual behaviors, 15.9% of IDUs reported having sex with FSWs/un-regular partners; 30% of them reported consistently use condom with FSWs/un-regular partners There are 33.1% of IDUs reported receiving condoms from intervention program But there is no evidence confirms that receiving condoms from program has significant effect on condom use with FSWs/un-regular partners of IDUs In other hand, receiving condoms program increases using condom with wives/girlfriends 17.3 times among IDUs who received condom as compared with those who did not (p<0.001)

In term of HIV/AIDS counseling and testing, there is not enough evidence to confirm those services have significant effect on HIV/AIDS prevention practices of IDUs in Son La

B Recommendation for HIV/AIDS program in Son La province

educator, commune health station, pharmacy and hotels…

In Son La, having HIV test and receiving counseling not show significant effect on reducing the high-risk behaviors Thus, the program should improve the quality of HIV/AIDS counseling services by strengthening capacity of health workers and peer educators Scaling up the voluntary counseling and HIV testing services as well as condom and needles provide services to make sure that all IDUs can easily access these services and they will practice HIV/AIDS prevention behaviors

Finally, the result of research should be used to advocate policy makers and other stakeholders for better understanding the situation of IDUs and providing more effective and practical supports for prevention program to reduce impacts of HIV/AIDS epidemic among this group in Son La as well as throughout Vietnam They can even facilitate to the integration of state programs in order to increase the effectiveness of this program

REFERENCEXDung, D V (2006) The relationship between risk behavior and HIV infection among male injecting drug users in Son La province, Vietnam. Mahidol University

Gary Reid, Genevieve, Costigan, A., (2002) Situation Asseseement of Drug Use in Asia in the context of HIV/AIDS Revisiting The Hidden Epidemic 40-62

Huong, N T T (2008) Effects of HIV/AIDS prevention outreach activities on HIV/AIDS knowledge and risk behaviors of young male IDUs in Ky Son, Nghe An, Vietnam. Unpublished Master of Art, Mahidol University, Thailands

MOH (2009) Report on review of activities in 2008 and planning in 2009 for national HIV/AIDS prevention program (No 120/BC-BYT) Hanoi, Vietnam

MOH, & FHI (2005) HIV/AIDS estimates and projections 2005-2010, Medical Publishing House, Hanoi

MOH, & FHI (2006) Result from the HIV/STI intergrated Biological and Behavior Surveillance (IBBS) in Vietnam 2005-2006: Medical Publishing House

Son, V H (2009) Risk behaviors among male injecting drug users in Thanh Hoa province, Vietnam Unpublished Master of Art, Mahidol University, Thailand

Thanh, D C., Hien, N T., Tuan, N A., Thang, B D., Long, N T., & Fylkesnes, K (2008) HIV Risk Behaviours and Determinants Among People Living with HIV/AIDS in Vietnam AIDS Behavior Thao, L T L., Lindan, C P., Brickley, D B., & Giang, L T (2006) Changes in high-risk behaviors over time among young drug users in South Vietnam: a three-province study AIDS Behavior, 10(4 Suppl), S47-56

UNAIDS (2008) Report on the global AIDS epidemic Geneva: Joint UN Programme on HIV/AIDS, 2008 Geneva

UNGASS (2006) Second country report on following up to the declaration of

commitment on HIV/AIDS Reporting period: January 2003 – December 2005

Risk behavior among Injecting Drug Users (IDUs) in Thanh Hoa province, Vietnam

Vo Hai Son1, Phan Thi Thu Huong1, Nguyen Van Ky2,

Bui Hoang Duc2, Nguyen Ba Can3, Duong Thuy Anh1, Nguyen Viet Nga1

Abstract

This study examined the effects of an HIV/AIDS prevention program on IDU’s risk behaviors in Thanh Hoa province, Vietnam Data used was a cross-sectional survey of 414 male IDUs conducted by the Vietnam HIV/AIDS prevention project

A logistic regression assessed the effect of the program on risk behaviors of IDUs by controlling their demographic, sexuality, drug use characteristics, and HIV/AIDS knowledge

Findings showed that IDUs accessed the program were 52 to 64% less likely to share needles compared to those who did not (p<0.05) IDUs receiving free condoms were 12.3 times more likely to use them with their wives or girlfriends, and 3.4 times more likely to use them consistently with sex workers or non-regular partners compared with those who did not receive (p<0.05)

The program reduced IDU’s HIV risk behaviors and thus the program should increase accessibility to condoms, clean syringes and needle to strengthen the effect of intervention

Introduction

The first case of HIV infection in Vietnam was reported in 1990 in Ho Chi Minh City During 1991-1992 and in the first half of 1993, only 11 additional cases of HIV infection were reported However, in the second half of 1993 more than 1,100 additional cases of HIV infection were reported in provinces in the Southern Region and in the Southern part of the Central Region in Vietnam By 1998, HIV infection had been reported in all 61 provinces of the country (MOH, 2000) As of 31th December 2008, a cumulative total of 179,735 people had been reported as HIV positive, in which 71,119 people were diagnosed with AIDS, of whom 41,544 had died (MOH, 2009) However, the actual number of infections are much higher than the recorded number, with an estimated 295,000 people living with HIV/AIDS in 2008 and about 315,000 in 2010 (MOH & FHI, 2005) The HIV epidemic in Vietnam is classified as being concentrated with high prevalence among high risk populations, mainly injecting drug users (IDUs), followed by female sex workers (FSWs), and a low prevalence among the general population IDUs have accounted for most (75%) of the reported infection (MOH, 2009) Also, according to a 1994-2007 sentinel surveillance HIV prevalence of IDUs increased from 6% in 1996 to approximately 30% in 2005 (MOH, 2007) At the same time HIV prevalence among the general population (pregnant and military recruits), HIV prevalence remained relatively low, less than 1% in all places surveyed in Vietnam (MOH, 2007) Findings from different research in Vietnam demonstrat that IDUs who have high levels of risk such as multiple sexual partners, unprotected sexual intercourse, and sharing of needles and syringes are more likely to infect HIV(Go et al., 2006; Quan et al., 2009; Thanh et al., 2008)

Behavioral interventions such as needles and syringes exchange, condom distribution, and behavior change communication for IDUs have been shown to be successful in reducing their HIV risk behavior Many studies have been conducted to evaluate preventive interventions aimed at reducing sexual risk and sharing of needles and syringes among IDUs A meta-analytic review of sharing needles among IDUs in United States showed that such interventions were highly effective in reducing unsafe drug injection (Ksobiech, 2003) In addition, a meta-analytic review of 12 controlled trails among IDUs in United States indicated that HIV/AIDS prevention interventions were highly effectively in reducing unprotected sex and unsafe drug injection among IDUs, but effects of interventions on needle sharing were non-significant (Crepaz et al., 2006) A recent research of behavioral interventions for IDUs in Vietnam also found that these interventions were effective in reducing risk behaviors (Huong, 2008; Thanh et al., 2008)

1 C c Phòng, ch ng HIV/AIDS, B Y tụ ố ộ ế

In order to control the HIV epidemic, the Vietnam government promulgated the national strategy on HIV/AIDS prevention and control in 2005-2010, and vision until 2020, in which the harm reduction interventions for high risk population were one of the important action plans to control HIV transmission in Vietnam (Government, 2004) At the 2006 national conference for this program it was declared that harm reduction interventions were a top priority for preventing the spread of HIV Harm reduction accounted for almost one-fifth (20%) of total funds available to intervene for IDUs and FSWs (MOH, 2006) The aim of this paper is to examine the effect of HIV/AIDS prevention program on HIV risk behaviors among IDUs in Thanh Hoa provinces, Vietnam

Research Methods

Background of HIV/AIDS prevention project

Thanh Hoa is one of 20 provinces involved in the Vietnam HIV/AIDS Prevention Project (VNHPP) funded by the World Bank for five years (2006-2011) Since 2006, under the VNHPP project, Thanh Hoa has focused on three main components namely [i] Exchanging needles and syringes [ii] Distributing condoms and [iii] Counseling for behavior change on the basis of setting up collaborators, and peer- educators’ network and health workers in the province Its main objectives are to increase the percentage of IDUs with safe injecting practices, for them to take part in harm reduction activities run by peer-educators, to increase the percentage of FSWs using condoms, and to ensure availability of needles and condoms used in the harm reduction program in the whole province

Data Collection

A cross sectional survey was carried out among IDUs from four project districts: Quang Xuong, Quan Hoa, Tinh Gia and Dong Son in Thanh Hoa Participants in this survey were selected by a snowball sampling method among IDUs who had been introduced by pear educators through distributing a coupon Those eligible were 15 years of age or older, residents of the study area, and injecting drugs in the six months prior to the conducted survey The local health care workers in charge of the HIV program at commune health centers made contact to invite them to participate in the study Data were collected June to September of 2008 by trained field teams from the provincial center for HIV/AIDS control, and these were supervised by a national advisory team from the Vietnam Administration of HIV/AIDS Control Using a specially designed questionnaire, the teams collected information on socioeconomic and demographic characteristics; HIV counseling; drug use and sexual behaviors The interview process was by consent and anonymous No names or other identifying information was collected and all information provided by participants was kept confidential

Data Analysis

We performed a logistic regression analyze to derive crude estimates of association between predictors and outcomes The outcome variables were condom use with regular partners during sexual intercourse in the previous month, use of condoms consistently with female sex workers (FSWs) or non-regular partner during the previous 12 months, and the sharing of needles and syringe with drug use partners in the previous month Using condoms consistently with FSWs or non-regular partners was defined as always use condoms in all sexual intercourse with FSWs or non-regular partners in the previous 12 months Needle and syringe-sharing behaviors were defined as either borrowing needles/syringes from drug user partners or handing to them during the last month

A multivariate logistic regression was used to examine the associations of independent variables with the outcomes The odd ratios (ORs) and significant value (P) were calculated to estimate and measure the association Variables were selected for the multivariate model on the basis of prior knowledge about the relationship between them and the outcome, the magnitude of the odd ratios in univariate analysis and specific research interests

Results

Socio-demographic characteristics of participants

accounted for the majority of participants (69.8%); the Kinh is the majority ethnic group in Vietnam, constituting 87% of the total population (2003 national census) Other groups (Thai and Muong) were 30.2% In term of mobile status, almost one-third (27.6%) of participants reported that they had ever been to other provinces for more than one months during the previous 12 months at the survey

Drug use behavior

The mean duration of drug injection of the participants was years (standard variation 3.6, range 1-51 years), more than half (55.6%) of participants had a history of drug injection of years or longer, and 44.2% of them had used drugs for less than years Almost a half (46.6 %) of participants injected drugs twice or more per day Regarding to drug injecting sharing behavior, 15% of participants reported sharing needles and syringes in the last month (Table 1)

Table 1: Drug using characteristics of participants (N=414)

Characteristics Frequency Percentage Descriptive Statistics Duration of drug injection

< years 183 44.2 Mean: 5; SD: 3.6

≥ years 230 55.6 Median:

Max: 51; Min: Frequency of drug injecting use during last month

< time per day 101 24.4

1 time per day upload.123 doc.net

28.5

≥ times per day 193 46.6

Sharing needles and syringes during last month

Yes 62 15.0

No 351 85.0

Total may not add up to 100% for some variables because of missing values

Sexual behaviors

About 40% of participant reported to have sex with FSWs or non-regular partners during the 12 months prior to the survey The majority of participants (81.8%) who had sex with FSWs or non-regular partners during the previous 12 months reported to use condoms consistently Regarding to IDUs who had sex with their wives or girlfriends in the last month, 46.5% of them reported using a condom the last time they had sex (Table 2)

Table 2: Sexual behavior characteristics of participants (N=414)

Characteristics Frequency Percentage

Have sex with FSWs or non-regular partner during the last 12 months

Yes 165 39.9

No 249 60.1

Use condom consistently with FSW or non-regular partner during the last 12 months

Yes 135 81.8

No 30 18.2

Use condom with wives or girlfriends at the last sex intercourse

Yes 145 46.5

No 167 53.5

Knowledge on HIV/AIDS and HIV test

Table 3: Characteristics on knowledge about HIV/AIDS and HIV test

Characteristics Frequency Percentage Descriptive Statistic

Knowledge about HIV/AIDS Mean score: 8.9

Good 281 67.9 Median: 10; SD: 2.2

Poor 133 32.1 Max: 11; Min:

Ever had HIV test

Yes 127 30.9

No 295 69.1

Accessed the HIV prevention intervention program

Table highlights that about 75% of IDUs received counseling on HIV/AIDS from health workers In addition, most of the IDUs received needles and syringes from a program during the last months (87%), while only 56% received condoms from a program during the same period These figures were much higher than that of Global Fund project in 20 provinces of Vietnam, 16.4% and 41.1% respectively (Thanh et al., 2008)

Table 5: Frequency of IDUs by accessed the program (N=414)

Characteristics Frequency Percentage

Received a counseling on HIV/AIDS from health workers

Yes 309 74.6

No 103 24.9

Received needles and syringes from program during the last months

Yes 359 87.1

No 53 12.9

Received condom from program during last months

Yes 231 55.8

No 181 43.7

Total may not add up to 100% for some variables because of missing values

Determinants of needles and syringes sharing behaviors

In the multivariate logistic regression on sharing needles and syringes, results show that the mobile status of IDUs has a significantly increased probability of sharing needles and syringes (OR=2.4, 95% CI 1.3-4.5) Surprisingly, IDUs who have a good knowledge of HIV/AIDS are more likely to share needles and syringes than those who have poor knowledge of HIV/AIDS (OR=2.4, 95% CI 1.2-5.0) However, having a HIV test had a positive effect on reducing the sharing of needles and syringes among IDUs (OR =0.4, 95% CI 1.2-5.0) Both receiving a counseling, and free needle/syringe had a positive effect on reducing the unsafe injecting behavior (OR= 0.36 95%CI 0.2-07; and OR=0.48, 95% CI 0.2-0.9 respectively) (Table 6)

Table 6: Logistic regression analysis of factor for sharing of needles and syringes during the last months among IDUs

Factors N % Odd Ratio 95% CI

Age

< 25 113 21.8

25 -34 193 12.4 0.58 0.2-1.6

≥35 87 10.3 0.84 0.2-4.4

Education

Primary school or lower 90 13.3

Secondary school 175 18.3 1.19 0.5-2.8

High school or higher 145 12.4 0.76 0.3-2.0 Marital status

Not married 179 18.4

Ethnic groups

Kinh 288 15.6

Thai or Muong 125 13.6 1.19 0.6-2.5

Mobile status

No 296 12.2

Yes 113 77.0 2.41* 1.3-4.5

Duration of drug injection

< years 182 19.8

≥ years 230 11.3 0.85 0.4-1.6

Frequency of drug injecting use in the last month

< time per day 101 12.9

1 time per day uplo

ad.123d oc.net

16.1 1.64 0.7-4.0

≥ times per day 193 15.0 1.41 0.6-3.3

Sexual intercourse with FSWs or non-regular partner during the last 12 months

No 248 12.5

Yes 165 18.8 1.6 0.8-3.1

Knowledge about HIV/AIDS

Poor 132 9.8

Good 281 17.4 2.4* 1.2-5.0

Ever had HIV test

No 284 18.0

Yes 126 7.9 0.41* 0.2-0.9

Received a counseling on HIV/AIDS from health workers during the previous months

No 103 28.2

Yes 308 10.4 0.36* 0.2-0.7

Received needles and syringes from program during last months

No 52 21.2

Yes 359 13.9 0.48* 0.2-0.9

N: 399, LR chi-square: 47.1, Sig <0.01, Pseudo R: 0.14, * Sig level of 0.05

Determinants of sexual behaviors

The result of the multivariate regression analysis shows that getting married or having sex with FSWs or non-regular partners during the previous 12 months among IDUs was significant associated with reducing condom use with wives or girlfriends in the last sex intercourse in the last months Furthermore, receiving counseling from health workers also had a negative effect on condom use with their wives or girlfriends However, receiving free condoms from the program during the previous months increased probability of use condoms with wives or girlfriends the last time they had sex in the last month (OR 12.3, 95% CI 6.3-23.9) (Table 7)

Table 7: Logistic regression analysis of factor for using condom with wives of girlfriends in the last sex intercourse in the previous months

Factors N % Odd Ratio 95% CI

Age

< 25 78 53.8

25 -34 153 44.4 1.08 0.5-2.5

≥35 81 43.2 1.56 0.6-4.3

Education

Primary school or lower 72 18.6

Secondary school 138 44.2 0.72 0.4-1.5

Not married 81 61.7

Current married 231 41.1 0.36* 0.2-0.9

Ethnic groups

Kinh 213 41.3

Thai or Muong 99 57.6 0.64 0.3-1.3

Mobile status

No 299 47.2

Yes 80 45.0 0.90 0.5-1.6

Sharing needles and syringes during last month

No 263 47.5

Yes 48 41.7 0.64 0.3-1.4

Sexual intercourse with FSWs or non-regular partner during the last 12 months

No 187 50.3

Yes 125 40.8 0.39** 0.2-0.7

Knowledge about HIV/AIDS

Poor 99 40.4

Good 213 49.3 1.48 0.8-2.7

Ever had HIV test

No 215 42.3

Yes 95 55.8 1.83† 1.0-3.4

Received a counseling on HIV/AIDS from health workers during the previous months

No 77 48.1

Yes 234 45.7 0.44* 0.2-0.9

Received free condom from program during last months

No 39 43.6

Yes 272 46.7 12.3*** 6.3-23.9

N: 303, LR chi-square: 96.6, Sig <0.001, Pseudo R: 0.23, †Sig level of 0.1 * Sig level of 0.05

Regarding the use of condoms consistently with FSWs or non-regular partners during the previous 12 months, the research indicates that IDUs who get married are 80% less more likely to use condom consistently with FSWs or non-regular partner than those who were single (p<0.05) IDUs, who are of the ethnic group Kinh, are 8.1 times more likely to use condoms consistently with FSWs or non-regular partner than other ethnic IDUs Also, IDUs who reported to share needle and syringe were 63% less likely to use condom consistently than those who did not share needle and syringe, but significance are low level (p<0.1) However, receiving free condoms from the HIV/AIDS prevention program increased the probability of using condoms consistently with FSWs or non-regular partner during the previous 12 months with OR =3.24, 95% CI 1.2-8.9 Other components of the program were not showed in this data (Table 8)

Table 8: Logistic regression analysis of factor for using condom consistently with FSWs or non-regular partner in the previous 12 months

Factors N % Odd Ratio 95% CI

Age

< 25 59 79.7

25 -34 78 84.6 1.74 0.4-7.3

≥35 28 78.6 1.73 0.3-10.0

Education

Primary school or lower 25 28.0

Secondary school 70 77.1 1.17 0.3-4.8

High school or higher 67 89.6 3.74 0.8-15.9 Marital status

Not married 85 88.2

Current married 80 75.0 0.20* 0.1-0.8

Thai or Muong 25 56.0

Kinh 140 86.4 8.1** 2.1-30.8

Mobile status

No 107 83.2

Yes 57 78.9 0.95 0.3-2.6

Sharing needles and syringes during last month

No 134 85.8

Yes 31 64.5 0.37† 0.1-1.0

Knowledge about HIV/AIDS

Poor 54 83.1

Good 111 81.1 1.09 0.4-3.1

Ever had HIV test

No 116 82.8

Yes 48 81.3 0.87 0.3-2.6

Received a counseling on HIV/AIDS from health workers during the previous months

No 44 77.3

Yes 121 83.5 0.87 0.3-2.8

Received free condoms from program during last months

No 50 72.0

Yes 115 86.1 3.24* 1.2-8.9

N: 161, LR chi-square: 34.0, Sig <0.001, Pseudo R: 0.22, †Sig level of 0.1 * Sig level of 0.05

Conclusion

The findings suggest that the risk on cross spreading of HIV between IDUs, FWSs, and their sex partners is high in Thanh Hoa province A significant proportion (about 40%) of IDUs reported having sex with FSWs or non-regular partners during the previous 12 months, while about 20% of them reported not using condoms consistently with these sexual partners Otherwise, the majority (74.6%) IDUs reported to receiving counseling from health workers, but only about half (45.7) of them reported using condoms with their wives or girlfriends the last time they had sex Correspondingly, “condom not available” and “dislike use condoms” were among the major reasons for not using condoms among IDUs This study also found that IDUs who get married or were from an ethnic minority tended to inconsistently use condoms with their sex partners Regarding sharing needles and syringes, this research shows that IDUs who have good knowledge of HIV/AIDS are 2.4 times more likely to share needles and syringes than those who have poor knowledge It means that although IDUs have good knowledge on HIV/AIDS, they still did not concern the risk of HIV transmission when they craved for drugs A high proportion (15%) of IDUs reported sharing needles and syringes during the previous month These findings might indicate that needles and syringes are not easily obtained in the research sites Qualitative research in Thanh Hoa indicated that IDUs were sharing needles and syringes due to a lack of money or injecting in late evenings (Ngo, Schmich, Higgs, & Fischer, 2009) The proportion (15%) sharing needles and syringes in this study is similar to results in other studies in big province/cities in Vietnam (MOH & FHI, 2006; Thanh et al., 2008) It is argued that the proportion of IDUs sharing equipment, accompanied with the high HIV prevalence rate (29%) is why the HIV epidemic in Vietnam is predominantly concentrated among IDUs Although the spread of HIV though sharing needles and syringes is high in some countries in Asia, unsafe sexual intercourse is still the major way of HIV transmission in the world (UNAIDS, 2008) This research also showed that IDUs who reported to having sex with FWS during the last 12 months were less likely to use condoms with their wives or girlfriend, in addition, those who reported sharing needle and syringe were less likely to use condom consistently with FSWs or non-regular partners

unprotected sex and unsafe drug injection among IDUs, but effects of interventions on needle sharing were non-significant (Crepaz et al., 2006) Our finds also show that IDUs who received free needles and syringes are less likely to share their drug taking instruments than those who did not receive needles and syringes Also, those who received free condoms are more likely to use them with their wives and girlfriends, and are more likely to consistently use condoms with FSWs or non-regular partners than those who did not receive free condoms Providing counseling from health workers also increased the safe injecting practices among IDUs, however, using condoms were not influenced by counseling for both with regular sex partners and non-regular partners in this research

This study has several limitations and possible biases IDUs are a hidden population and difficultly access Sampling for the study was based on the peer educator network and thus may not be a representative sample of IDUs

Recommendations

It is recommended that other HIV intervention programs ensure that IDUs have access to condoms, and clean syringes and needles In addition, the program should strengthen capacity building for health workers, peer educators on counseling skills to make sure that all of IDUs who receive counseling will practice safe risk behaviors To prevent the spread of HIV from high-risk populations to general population, the program should further strengthen behavior change communication activities for IDUs and their families, especially for married IDUs of ethnic minority groups

References

XCrepaz, N., Lyles, C M., Wolitski, R J., Passin, W F., Rama, S M., Herbst, J H., et al (2006) Do prevention interventions reduce HIV risk behaviours among people living with HIV? A meta-analytic review of controlled trials Aids, 20(2), 143-157

Go, V F., Frangakis, C., Nam le, V., Bergenstrom, A., Sripaipan, T., Zenilman, J M., et al (2006) High HIV sexual risk behaviors and sexually transmitted disease prevalence among injection drug users in Northern Vietnam: implications for a generalized HIV epidemic J Acquir Immune Defic Syndr, 42(1), 108-115

Government (2004) National Strategy on HIV/AIDS prevention and control in Vietnam ultil 2010 with a vision 2020 (No 36/2004/QD-TTg) Hanoi: Vietnam Government

Ksobiech, K (2003) A meta-analysis of needle sharing, lending, and borrowing behaviors of needle exchange program attenders AIDS Educ Prev, 15(3), 257-268

MOH (2000) Review on HIV/AIDS epidemic situation 1990-2000

MOH (2007) HIV sentinel survellance Result 1994-2007 Hanoi, Vietnam

MOH (2009) Report on review of activities in 2008 and planning in 2009 for national HIV/AIDS prevention program (No 120/BC-BYT) Hanoi, Vietnam

MOH, & FHI (2005) HIV/AIDS estimates and projections 2005-2010

MOH, & FHI (2006) Result from the HIV/STI intergrated Biological and Behavior Surveillance (IBBS) in Vietnam 2005-2006: Medical Publishing House

Ngo, A D., Schmich, L., Higgs, P., & Fischer, A (2009) Qualitative evaluation of a peer-based needle syringe programme in Vietnam Int J Drug Policy, 20(2), 179-182

Quan, V M., Go, V F., Nam le, V., Bergenstrom, A., Thuoc, N P., Zenilman, J., et al (2009) Risks for HIV, HBV, and HCV infections among male injection drug users in northern Vietnam: a case-control study AIDS Care, 21(1), 7-16

Thanh, D C., Hien, N T., Tuan, N A., Thang, B D., Long, N T., & Fylkesnes, K (2008) HIV Risk Behaviours and Determinants Among People Living with HIV/AIDS in Vietnam AIDS Behav

UN (2004) HIV prevention among young injecting drug users Vienna, Austria: United Nations Publication

UNIQUE IDENTIFIER CODE in outreach INTERVENTION targeting sex workers who are drug users in vietnam

Nguyen Thu Van, Truong Hien Anh, Yasmin Madan Population Services International (PSI)

Abstract (Summary)

PSI Vietnam has adapted the Unique Identifier Code (UIC) information system to improve reach and quality of an outreach intervention targeting female sex workers (FSW) who are drug users This is the first outreach intervention that addresses the dual risk of unsafe sexual and injecting practices among this vulnerable population that is driving new HIV infections in Vietnam The UIC system is a simple anonymous client registration that can function as a monitoring tool to effectively improve program implementation as well as plan and make strategic decisions

I Background

Female sex workers who inject drugs (FSW-IDU) are an important source of new HIV infections in Vietnam’s concentrated epidemic HIV/STI Integrated Biological and Behavioral Surveillance 2006 (IBBS 2006) data shows that HIV infection among FSW was highly correlated with injection drug use Injecting FSW are 3.5 to 31 times more likely to be HIV-infected compared to FSW who are non-injectors Among street-based FSW in Hai Phong only 3% of FSW without a history of injection were HIV-infected compared to 55% of those who ever injected2 While commercial sex networks and injecting drug users (IDU) constitute most of the new HIV infections in Vietnam, FSW-IDU create a nexus between the two groups with the potential to greatly elevate the incidence of new HIV infections

Interventions across Vietnam target FSW and male IDU as part of a comprehensive response to the nation’s concentrated epidemic However, none of the programs for FSW address the dual risk of unsafe sexual and injecting practices among the sub-group of FSW-IDU1.

In addition to this, there are no programs targeting drug demand reduction among FSW who are non-injecting drug users (inhalers) and FSW exposed to drug use

With support from the President’s Emergency Plan for AIDS Relief (PEPFAR), PSI Vietnam received United States Agency for the International Development (USAID) funding to develop and implement an evidence-based intervention for FSW who are IDU and inhalers The objectives of the program include: increased correct and consistent condom use in high-risk relationships (commercial and non-commercial); increased uptake of HIV voluntary counseling and testing (VCT) services; reduced initiation of new IDU through existing FSW-IDU and reduced transition of FSW who inhale drugs to injecting drug use The program targets three types of sub-target groups – i) FSW-IDU; ii) FSW who are non-injecting drug users (FSW-ODU); and iii) FSW who are exposed to drug use

Given the unique nature of the project, PSI wanted to design a management information system (MIS) that would help track program coverage i.e number of FSW reached by type of sub-target group and match the communication messages to the risk behaviors of the different sub-target groups The project follows a themed approach to deliver focused messages for each of the intervention’s behavior objectives Each theme is based on a single concept identified by research, developed into messages and interactive communication tools and materials, and used by peer educators to target the sex workers Each FSW is assigned a UIC that allows the project to track patterns in drug use and exposure to out reach activities The UIC system measures exact number and type of FSW reached, the number of times a FSW is contacted and the type of messages delivered

II Major content

UIC with outreach program in other countries: In 2003, PSI developed a UIC system for monitoring the USAID funded -Drug Demand Reduction Program (DDRP) in Central Asia This simple system of anonymous client registration and tracking service usage was progressively adopted by all DDRP partners and sub-grantees in Kyrgyzstan, Tajikistan and Uzbekistan3

outreach worker ask the prompt question It should also be based on a recall system that remains constant, no matter which outreach worker has contact with the client

Adapting the UIC system in Vietnam:

Assessment of UIC variants: feasibility, preference

In order to determine the UIC system for use in Vietnam, PSI developed and tested different UIC combinations The criteria for selection included – ease of recall, ability of respondents to provide consistent condoms and assurance felt by respondents of the confidentiality provided by the UIC Findings from PSI’s pre-test showed that participants found all combinations easy to recall and provide consistent responses As the UIC did not ask for personal information such as full name and exact address, participants were willing to give information in this form for peer educators and medical doctors Participants had major concerns about the use of the information and the risk of being identified to authorities So, the respondents had to understand the use of UIC and the confidentiality of the information provided FSW were more comfortable with UIC variants where police or others would have the most difficulty using the information gathered for the UIC would to find them The variants were ranked based on the criterion of the level of difficulty for the police or others to identify them

As all combinations were easy to recall and based on simple questions, the respondents made the final decision based on the criterion of confidentiality The version selected as the UIC to be used in PSI’s project was- First letters of Father’s personal name, First letter of Mother’s personal name, First letters of place of birth, gender (Male: 1, Female: 2) and last two digits of birth year

Assessment of duplication

Table 1: Combinations of UIC based on names of university/college students.

Duplication Meet the

requirement Hanoi

(N = 2,177)

HCMC (N = 2,198) UIC111:

1 First letter of client’s Father’s personal name First letter of client’s Mother’s personal name

1 First letter of place of birth 2.80% 7.90% NO

UIC112:

1 First letter of client’s Father’s personal name First letter of client’s Mother’s personal name

2 First letter of place of birth 2.30% 7.90% NO

UIC222:

2 First letter of client’s Father’s personal name First letter of client’s Mother’s personal name

2 First letter of place of birth 0.50% 1.30% YES

Once the UIC combination was selected, it was important to ensure the applicability in Vietnam to avoid high rate of duplication In a standard system, the acceptable duplication rate is 5% or below To test the duplication rate, PSI ran an analysis from student names from universities and colleges in Hanoi and HCMC PSI’s research team randomly combined the name of male and female students with their home provinces A summary of the findings is presented in Table

Based on the above analysis, letters were finalized for the UIC combination In addition to this, PSI also compared actual UIC from a PSI’s Behavior Survey among FSW and FSW-IDU in 2008 to determine duplication rates Data was collected from 1,032 FSW and FSW-IDU in October 2008 Findings are presented in table below:

Table 2: Province level data of FSW from PSI Behavior Survey among FSW

Provinces Sample size Duplication

Ha Noi 190 1.05%

Hai Phong 260 1.15%

Quang Ninh 81 1.23%

Ho Chi Minh city 239 0.00%

An Giang 80 0.00%

Can Tho 182 2.20%

Total of the provinces 1032 0.97%

First two letters of Father’s name

First two letters of Mother’s name

Two letters code of province of birth

One digit of gender (male=1; female=2)

Last two digits of birth year

NG TH HN 82

NGTHHN282

Since August 2008, PSI in partnership with the Provincial Health Department (PHD) in Hai Phong has implemented the FSW-IDU outreach intervention using UIC to track reach and coverage of the target population In March 2009, the intervention was expanded to Quang Ninh through the Provincial AIDS Center (PAC) and then to additional provinces (Nghe An, and Ho Chi Minh city) in January 2010 Program experience has shown that the UIC system allows the project to target specific communication messages for different risk behaviors among different types of FSW and to track program efficiency (actual reach, not contacts) by target districts

III Results/ Benefit of using UIC in PSI FSW- IDU intervention 1 UIC helps tracking coverage

 UIC allows the program to track individual numbers of the target population reached This is richer data than the contacts as it allows for estimation of the size of the target group in the intervention area The chart below shows the difference between actual number of FSW reached compared to the number of contacts

Chart 1: FSW reached in Hai Phong by PSI outreach intervention ( First 12 months)

Chart 2: Cumulative FSW reached and contact made in Hai Phong

the hotspot areas mapped for FSW

HAI PHONG QUANG NINH

Month UIC reached

In month

New UIC In month

Month UIC reached

In month

New UIC In month

Aug-08 232 232

Sep-08 290 125

Oct-08 318 97

Nov-08 294 90

Dec-08 342 84

Jan-09 276 39

Feb-09 295 105

Mar-09 390 119 Mar-09 673 673 Apr-09 425 119 Apr-09 618 489 May-09 437 120 May-09 537 315 Jun-09 450 107 Jun-09 548 205 Jul-09 470 98 Jul-09 692 375

 UIC also allows the program to track reach by type of target group i.e number of street based FSW-IDU or number of entertainment-establishment based FSW-ODU

FSW reached in Hai Phong in months (1/3/2010 – 31/8/2010)

Type of reached venue Entertainment Establishment based Street based

Intensity FSW F–SW-IDU FSW-ODU FSW FSW-IDU FSW-ODU

1 time 289 35 14 9 4 1

2 times 76 9 1 - 2 1

3 times 55 8 - - 1

-4 times 36 6 2 1 -

-5 times + 354 60 10 4 6 2

Total individual reached 810 upload.123do

c.net 27 14 13

2. Mapping Concentration of Risk Behavior

UIC helps improve the efficiency of outreach work by prioritizing intervention areas within the project provinces to reach higher number of FSW-IDU The example below shows the need to prioritize outreach workers in Le Chan district within to improve program effectiveness Programmers used this information to change the schedule of the daily outreach activities

Chart 3: Proportion of FSW-IDU versus total FSW reached by district (data from July to December 2009)

UIC helps maintaining Intervention Continuity

UIC helps program team ensure continuity of the outreach activities even when the FSW has moved between venues and/or districts This is seen with the FSW as EE venues close or FSW move between venues for business reasons Outreach workers are able to compare UIC information to know if they have lost a contact and if that contact shows us in another intervention area

Province District Date UIC Contact Hai phong Ngo Quyen 04/09/2009 BIPHTB274 1 Hai phong Ngo Quyen 27/09/2009 BIPHTB274 2 Hai phong Ngo Quyen 12/10/2009 BIPHTB274 3 Hai phong Ngo Quyen 03/11/2009 BIPHTB274 4 Hai phong Ngo Quyen 21/11/2009 BIPHTB274 5 Hai phong An Duong 17/12/2009 BIPHTB274 6

4 UIC helps ensure delivering right messages

 Program targets different sub group with different messages Outreach workers are trained to deliver different messages to FSW depending on their risk behaviors Programmers want to check if outreach workers convey the right message to the right sub group For instant, the message on reduction of initiation of injecting drug should be conveyed only to sex workers who inject drug UIC helps the intervention ensure FSW receive the right message

Chart 6: UIC shows whether the right messages are reaching the right target group FSW reached by type with provided themes (1/1/2010 – 31/3/2010)

Total UIC reached/ Provided theme

FSW 551

FSW-IDU 91

FSW-ODU 28

Healthy client and negotiation -

-Break The Cycle - 140

-Condom use correctly 106 41

Female condom and variety card 273 136 24

VCT promotion 205 143 28

Prevention of drug initiation message delivered 140 times to 91 FSW-IDU in the reporting period

5 UIC helps the intervention track individual SW usage of HIV prevention products and services

 Outreach workers collect information on the type and number of HIV prevention products (male condoms, female condoms, water-based lubricants) delivered to the FSW As this information is collect by UIC, it allows for analysis of the total number of products received by the target group It also allows for additional analysis in case new products (example female condom) are introduced and the program wants to track repeat use and not just trials Similarly, UIC allows the program to monitor service referrals (example VCT promotion)

Chart 7: Tracking FSW by UIC helps monitor product and service promotion Query-Receiving female condom time count

UIC Detail Frequency of receiving

# of female condom received

Type of FSW PE name

LINHHP279 6 18 FSW Nga

TIHOQT283 6 14 FSW-IDU Hoi

TULIHP281 5 12 FSW-ODU Thanh

LICUHP280 5 10 FSW-ODU Loan

TUNHHP283 5 10 FSW Que

HOHUPT286 5 10 FSW Thanh

BIKHYB285 5 10 FSW-IDU Nga

HULIHP277 5 10 FSW Loan

HUXUHP289 5 10 FSW Thanh

NGLATH285 5 10 FSW Hoi

Total records found 242

Chart 8: UIC tells us how many FSW were escorted by risk behavior And her contact

infor is unbrokenThis SW

Escort to services

# escort times # FSW

(UIC counted))

# FSW-IDU (UIC counted)

# FSW-ODU (UIC counted)

Total escorted (UIC counted) VCT (HIV

test)

70 42 14 10 66

IV Lesson learned:

 The UIC should be considered as a part of a comprehensive system to ensure client anonymity, when working with at risk group FSW-IDU in Vietnam

 The training on UIC for peer educators, outreach workers and post –training activities considered most important to roll out UIC in all projects Staff turnover was an additional issue affecting the fully buy-in from intervention organization

 UIC will be an effective tool to measure the success of linkages within outreach and services to MARPs

Reference:

1 Consultation of Investment in Health Promotion (2008) Female Sex Workers who Inject Drugs Needs Assessment Report

2 Ministry of Health (2007) Results from the HIV/STI Integrated Biological and Behavioral Surveillance (IBBS) in Vietnam 2005-2006

3 USAID in Central Asian Republics website USAID funded Drug Demand Reduction program in Uzbekistan, Tajikistan and Kyrgyzstan - Unique Identifier Code http://centralasia.usaid.gov/datafiles/upload/DDRP_Unique_Identifier_Code.pdf

PSI Vietnam Outreach program targeted FSW-IDU ESCORT AND REFERAL REPORT

SUMMARY OF THE MAJOR FINDINGS FROM AN EVALUATION OF THE PILOT METHADONE MAINTENANCE THERAPY PROGRAM IN

VIETNAM

Authors: Nguyen Thanh Long1*; Pham Duc Manh1; Nguyen Thi Minh Tam1;

Nguyen Thi Huynh1, Tran Vu Hoang2; Nguyen To Nhu2; Tran Thi Thanh Ha2;

Rachel Burdon2; Chi Nguyen2; Stephen J Mills2; Pham Huy Minh3, Kevin Mulvey4,

Nguyen Thi Minh Ngoc3, Le Truong Giang5; Tieu Thi Thu Van5;Vu Van Cong6

(*) Presenting author

1 Vietnam Administration of HIV/AIDS Control, Ministry of Health 2 Family Health International, Vietnam

3 US Agency for International Development (USAID), Vietnam country office 4 SAMHSA, PEPFAR Vietnam

5 Provincial AIDS for HIV/AODS Control Committee, Ho Chi Minh City 6 Provincial HIV/AICS Control Center, Hai Phong city

Summary: In 2008, a Methadone Maintenance Therapy (MMT) pilot in Hai Phong and Ho Chi Minh City was initiated to reduce high-risk behavior and HIV transmission in heroin dependent individuals A cohort of 965 patients in Hai Phong and Ho Chi Minh City (HCMC), enrolled in the MMT program were administered a questionnaire containing questions on drug use, sexual behavior and quality of life before and during treatment They were tested for HIV, HBV and HCV infections, and also undertook random urine tests to measure ongoing illicit opioid use After nine months, retention in the MMT treatment program was 90% The key reason for stopping treatment was being sent to mandatory drug rehabilitation centers, especially in HCMC The rate of illicit opioid use (determined by urine testing) declined from 100% at baseline to 18% at nine months Of those using illicit drugs, 56% reported injecting while the rest reported smoking Sexual activity increased over time, from 48% to 65% Consistent condom use with commercial sexual partners remained stable over time at around 93%- 96%, while condom use with regular sex partners increased from 37% to 41% Only one new case of HIV was detected and new cases of HBV and 72 cases of HCV were detected Quality of life was reported to significantly improve in the first months on MMT and then remained constant over the next months out to months These preliminary data demonstrate a significant reduction in heroin use and other risk behaviors The increase in quality-of-life indicators shows that patients are benefiting from MMT in multiple life domains

Keywords: MMT, evaluation, illicit opioid drug use, injecting drug user, Vietnam

Background; In Vietnam, as other regions in Asia, injecting drug users (IDUs) have been the population most severely affected by HIV epidemic According to Ministry of Publish Security, there were about 170,000 IDUs in Vietnam by the end of 2008, of them approximately 30% were living with HIV or will become infected with HIV (1) Sharing of syringes and injecting equipment is a well-known route of HIV transmission and has been shown to be a primary determinant of HIV spread among IDU in Vietnam (2) Additionally, IDU can be involved in high-risk sexual behavior, especially with non-injecting partners, making them a potential bridge to transmit HIV to other low risk populations (3)

In 2006, the Vietnam Administration of HIV/AIDS Control (VAAC), Ministry of Health (MoH) began to plan for a pilot program on opioid 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, methadone maintenance treatment (MMT) has been associated with reduced rates of illicit drug use, needle sharing and lower HIV incidence (4,5)

In 2008, the MMT pilot program was established in Hai Phong and HCMC, two provinces where the prevalence of HIV amongst the IDU population is among the highest in Vietnam The objective of the pilot program is to reduce high-risk behavior and HIV transmission in heroin dependent invididuals

followed over months Data were collected through personal interviews before treatment, at months, months, and months after commencing treatment

Biological testing: Study participants provided ml venous blood to quantify HIV, HBV and HCV infection, and 5ml urine to measure opioid use at baseline and months

Data collection began in January 2009 Data was entered in Microsoft Access and statistical analysis was performed using SAS for for Windows version 9.2 (SAS Institute, Inc., Cary, NC) statistical software package

Results

Baseline characteristics: The median age for the study population was 30 years (range, 16.6 to 58 years); the majority were male (95%) On average, the duration of drug dependence was 7.3 years The most frequently used drug in the past 30 days before beginning MMT program was heroin (99.5%) The reported use of other drugs was uncommon, (less than 1% of surveyed 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 For the month prior to commencing methadone, the majority of patients used heroin two to three times a day (63.2%) and about 35% used heroin four times or more a day

The prevalence of blood-borne diseases among the study population at baseline was at very high level, 34% for HIV, 16% for Hepatitis B and 60% for Hepatitis C The HIV prevalence among patients enrolled in the MMT study was 27% in Hai Phong and 42% in HCMC which is slightly different from the findings reported in the 2006 IBBS 2006 (69% in Hai Phong and 34% in HCMC) This could be due to the fact that those enrolled in the pilot MMT program are not representative of the general IDU population given the strict selection and eligibility criteria to start treatment

Treatment retention and compliance: Overall, 90% of patients in the study were retained on methadone treatment at months At nine months, 94 patients had stopped treatment including who had died The key reason for stopping treatment was being sent to a mandatory drug rehabilitation center, especially in HCMC Most patients showed strong adherence to MMT with the rates of missing a dose for five days or more being extremely low (2.3% at months and 0.9% at months)

Opioid Drug use over time: Illicit opioid drug use was 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 The rate of illicit opioid use declined from 100% at baseline to 18% at nine months follow-up Self- reported “any drug use” was 10% at ninth months ART patients tended to report use drugs more than those who were not on ART (22% comparing to 17% at months) This is likely to reflect under-dosing of ART clients who need higher doses of MMT due to drug interactions between some ARV drugs and MMT

Figure 1: Illicit drug use over time, combined urine tests and self-reported

Of those, who continued using drugs, the proportion who injected drugs reduced from 87% before MMT to 56% at months Needle sharing in the month before interviews was very low, with only one individual reporting sharing needles with other injectors during the months of MMT 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

particularly for Hepatitis C

Sexual behavior over time: Sexual activity increased over time with 48% reporting sexual intercourse with partners at baseline (46% with regular partners and 3% with commercial or casual partners) compared to 65% at months (61% with regular partners and 6% with sex workers)

Figure 2: Sexual behavior over time

Consistent condom use with commercial sexual partners remained stable at 93%-96% over time Consistent condom use with regular sex partners increased from 37% to 41% Those who were HIV infected reported an increase in consistent condom use with regular partners, from 46% at baseline to 68% at months However, there is still a need to expand communication and counseling about safe sex behaviors at treatment sites

Quality of life: Quality-of-Life scores revealed improvements in physical health (from 68 to 76), psychological health (from 56 to 71), social factors (from 53 to 59) and environmental factors (from 59 to 67) The improvements were substantial during the first months, but remained constant thereafter

Figure 3: Quality of life over time

Implications

These preliminary data demonstrate a significant reduction in heroin use and other risk behaviors in clients on MMT Needle sharing behavior among those still injecting was significantly lower than rates found among IDU not on methadone measured in surveillance data The increase in quality-of-life indicators shows that patients are benefiting from MMT in multiple life domains

Reference

1 Ministry of Public Security, Report on prevention and control of drugs in 2008 and 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

2 Hien, N T., L T Giang, et al (2001) Risk factors of HIV infection and needle sharing among injecting drug users in Ho Chi Minh City, Vietnam J Subst Abuse 13(1-2): 45-58

3 IBBS Technical team (2006) Results from the HIV/STI Integrated biological and Behavioral Surveillance (IBBS) in Vietnam

4 Pang et al., (2007) Effectiveness of first eight methadone maintenance treatment clinics in China AIDS, Suppl 8:S103-S107

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

“That extra shot in the arm” - using strategic behavioral communications to improve and scale up MARP HIV

prevention programming in Cambodia

Author: Caroline Francis, FHI Vietnam

Issues

HIV prevention is at a crossroads Old-fashioned prevention messages and interventions have done little to abate the epidemic Vaccines and virus-killing microbicides are not working Other solutions, like treating our way out an epidemic or circumcising every man in the developing world, are widely impractical Despite our best efforts, millions of people globally continue to contract HIV each year “HIV prevention is what will require that extra shot in the arm,” said Peter Piot in his final public interview as the Executive Director of UNAIDS But what does that mean? In an age where even the poorest and most isolated people are bombarded with messages, where conditions that drive HIV transmission are dynamic and complex, and where, funnily enough, people don’t always easily fit into the categories we subscribe for them (the sex worker, the man who loves men, the drug user), how can we position HIV prevention as relevant, important and easy for the most vulnerable woman, the man with multiple sexual partners, and the pregnant mother?

Description

In Cambodia, implementers at FHI asked these tough questions Led by medical anthropologist, Caroline Francis and strategic behavioral communications expert Sea Sokhon, they spent one year between 2007-2008 deconstructing FHI’s most important HIV prevention initiatives – one focusing on female sex/entertainment workers (EWs); one reaching men who have sex with men (MSM), and interventions targeting the male clients of sex workers Overall programmatic “reach” was good, but each program operated in vertical, simplistic, non-systematic ways While HIV prevalence was indeed declining, STI prevalence among EWs and MSM was not Uptake of STI services and HIV counseling and testing were low; only 17% of entertainment workers were using STI services and less than 10% of EW and MSM clients had availed counseling and testing services in 2008 And condom use data that indicated high condom use with both regular and non-regular partners was suspect, with almost 30% of EWs reporting an abortion in the past year (Cambodian Behavioral Sentinel Surveillance 2007) Critical analysis indicated that FHI’s programs had been designed with the messages in mind, rather than the people – our clients, and those who influence or support them

Using behavioral research, programmatic data and social marketing principles, we designed new branded initiatives: SMARTgirl, an HIV prevention and care program for women in the entertainment industry; MStyle, a peer-led network to improve the sexual health among men who have sex with men and transgendered people; and You’re the Man!, an interpersonal and mass media initiative that strives to challenge gender norms and promote male responsibility for positive health

These targeted, but inter-related, programs – where consistent, reinforcing interventions and messaging recognize that people interact with one another and are not defined simply by what job they or where they socialize or with whom they have sex – uses multiple strategies to impact behavior Strategies that:

 Make products, services and healthy behaviors both relevant and appealing  Emphasize access and affordability

 Make healthy choices, easy choices

FHI designed offerings that strive to meet our customer’s needs, that lower barriers and increase benefits, and deliver education, goods and services where they are most needed

Results

following:

 Health service referrals shot up fivefold as part of the core prevention package of services provided to individuals during outreach contacts More than 30,000 STI, reproductive health and counseling and testing referral slips have been collected in SMARTgirl, an increase in service uptake of 133% for STI care and treatment and 198% for HIV counseling and testing

 Condom social marketing efforts have increased by 120% and reliance on free distribution reduced by 28% in SMARTgirl and MStyle

 MStyle reached 7588 individuals, or 77% of MSM estimated to be residing in Phnom Penh, Kandal and Banteay Meanchey province SMARTgirl reached 11,000 persons, or 61% of women working in the entertainment industry across 10 priority provinces Each individual is reached an average of seven times per year, where we can provide a myriad of targeted messaging, products and services

 Formal endorsement from the Cambodian government has allowed for FHI and our partners to rewrite standard operating procedures for HIV prevention among most at risk populations, paving the way for the Continuum of Prevention to Care and Treatment (CoPCT) approach, which replaces outdated 100% condom use policies

 Reality-based television and interpersonal communications programs like You’re the Man! are allowing space for dialogue on gender disparity, violence and destructive norms that influence HIV vulnerability More than 10,000 men and women sent SMS or internet messages to vote for favorite contestants or make comments on Season episodes

Lessons learned

Strategic behavioral communications must work together with program staff and implementers to examine the evidence, articulate barriers for positive health and develop strategies based on insight from MARP clients themselves

Author’s Biography

IMPACTS OF MASS MEDIA EXPOSURE AND LANGUAGE BARRIER ON COMPREHENSIVE HIV/AIDS KNOWLEDGE AMONG “DZAO” ETHNIC MINORITY IN YEN BAI PROVINCE, VIETNAM

Phan Thi Thu Hương-VAAC, Nguyen Thuy Duong, Vo Hai Son at all Abstract

This study aimed to examine the effects of mass media exposure and the language barrier on comprehensive knowledge of HIV/AIDS among 805 “Dzao” ethnic minority population in Yen Bai province, Vietnam when controlling for socio-demographic characteristics Secondary data came from the survey on HIV/syphilis infection rate, and risk behaviors related HIV transmission, among some ethnic minority groups in Vietnam.

The results of binary logistic regression indicate that language barrier is the factor affecting comprehensive knowledge of HIV/AIDS The people who could communicate in Vietnamese were 2.8 times more likely to have comprehensive knowledge of HIV/AIDS than those could not communicate in Vietnamese

The study’s result suggested that communication strategy in HIV/AIDS prevention should be further interested in ethnic minority population Communication materials and programmes should be designed in both local language and Vietnamese language, so that they can access HIV/AIDS information easily even they cannot communicate in Vietnamese language.

I. Introduction

The reasons are that (1) Ethnic minorities are part of the general population and behaviors of general population are not as risky as those of high risk groups; (2) socio-demographic characteristics of ethnic minority groups differ from other population in the field of culture, education level among other characteristics and live in remote areas Therefore, it is difficult for them to access general information as well as gain knowledge, especially about HIV/AIDS

Yen Bai is a Northern agricultural province with 30 ethnic minority groups, of which “Dzao” ethnic minority group makes up 10.31% of the total population While there is a cultural predisposition toward premarital sex among some ethnic minority groups, including “Dzao” people, these groups are not well-equipped with knowledge about human reproduction and sexually transmitted diseases (Population Council, 2007) In addition, a male or female can have many lovers and they are now independent in exploring romantic relationships as well as mate selection “Young people in romantic relationships have more opportunities to spend time alone with their partners without their parents’ supervision” (Population Council, 2007) This condition makes it is easier for them to have premarital sex Especially, it is very difficult for ethnic minorities groups to access communication program because they use local language From the above issues, it is necessary to carry out a study to further understand HIV/AIDS knowledge among the “Dzao” ethnic minority group in Yen Bai province

The objective of this study is to examine the impact of mass media exposure and language barrier on comprehensive HIV/AIDS knowledge Not only would the findings and recommendations suggesting appropriate interventions for “Dzao” ethnic minority group, especially for “Dzao” youth, but they would also contribute to develop interventions for other ethnic minorities as well as for an effective comprehensive National HIV/AIDS Prevention Plan for Vietnam

II Methodology

This survey carried out by the Vietnam HIV/AIDS Prevention Project funded by the World Bank Indicators of the survey were developed based on National Monitoring and Evaluation indicators The questionnaire used in this study included questions on (1) socio-demographic characteristic, (2) knowledge of HIV/AIDS, (3) mass media exposure and (4) ability to communicate in Vietnamese The sample size of this study is 805 “Dzao” ethnic minority aged 15-49 years

control variables (sex, age, marital status and education level) Some new variables were defined for this analyses such as level of HIV/AIDS knowledge includes categories namely, comprehensive and non-comprehensive Comprehensive knowledge of HIV/AIDS if respondents corrected answers of total questions related to HIV/AIDS knowledge based on UNGASS indicators Non-comprehensive knowledge of HIV/AIDS if respondents corrected answers less than above questions

Frequencies and cross tabulations were used to describe socio-demographic characteristics, mass media exposure and language barrier as well as level of HIV/AIDS knowledge of respondents Binary logistic regression was used to examine the relationship between each independent variables (main independent and control variables) and dependent variable (level of HIV/AIDS knowledge)

III Results.

1 Socio-demographic characteristics of the respondents

The proportion of respondents is quite equivalent between male and female, 49% and 51% respectively On average, the age of respondents was quite young with a median age of 28 although ages ranged from 15 to 49 The major proportion of respondents was within the 20-24 age group Regarding to marital status of respondents, most of them, 93% have ever married, while only 7% of them were single Similar to other ethnic minority groups in Vietnam, as well as in other countries, education level in this group was quite low with more than a half of respondents having never been to school

There are two types of language used among this ethnic minority group The first one is ethnic language and the second one is Vietnamese language All respondents in this study can communicate in local language but not all of them can communicate in Vietnamese language (36%)

The mass-media exposure among respondents including reading daily newspaper, listening to the radio and watching television Except illiterate respondents, nearly a half (47%) of the rest have not read daily newspaper and 32% of them read less than times per week Reading several times per week had the lowest proportion of reading newspaper by respondents The proportion of people who did not listen to the radio and watch television is quite high, 36% and 32% respectively The proportion of people listening to the radio several times per week made up 29% and the lowest proportion related to listening to radio is about 2-4 times per week at 13% Regarding to watching television, the highest proportion are watching several times per week (34%) and the lowest proportion is similar to listening to the radio Only 15% of respondents watched television about 2-4 times per week

2 Knowledge on HIV/AIDS

Percentage distribution of people having knowledge about HIV/AIDS for each question related to the ways of preventing HIV transmission and misconceptions about HIV transmission The proportion of people that recognize sex with only one faithful, uninfected partner can reduce the risk of HIV transmission and using condoms can reduce the risk of HIV transmission is quite high (78% and 70% respectively) The proportion of people that think sex with only one faithful, uninfected partner cannot reduce the risk of HIV transmission and using condoms cannot reduce the risk of HIV transmission are the same, registering just 9% and the proportion of respondents who not know how to answer the question and question are at 13% and 22% respectively For two misconceptions about HIV transmission, the proportion of respondents who reject the misconception that a person can get HIV from mosquito bites (45%) and the misconception that a person can get HIV by sharing a meal with someone who is infected (41%) is higher than the proportion of respondents who not reject above misconceptions at 31% and 33% respectively

According to UNGASS indicator on HIV/AIDS knowledge, only 14% of respondents have comprehensive knowledge while 86% of respondents have non-comprehensive knowledge

Percentage distribution of level of HIV/AIDS knowledge by socio-demographic characteristic, mass-media exposure and language ability Using Chi-square to test relationship, the result found that socio-demographic characteristics and HIV/AIDS knowledge are significantly associated except age In detail, sex and HIV/AIDS knowledge are significantly associated at p<0.001; marital status and HIV/AIDS knowledge are significantly associated at p<0.05; education level and HIV/AIDS knowledge are significantly associated at p<0.01

of reading daily newspaper

In detail, frequency of listening to radio and HIV/AIDS knowledge are significantly associated at p<0.05; frequency of watching television and HIV/AIDS knowledge are significantly associated at p<0.01 The final factor is language barrier that is also significantly associated with HIV/AIDS knowledge at p<0.001

Proportion of male having comprehensive knowledge on HIV/AIDS is higher than female (20% and 8% respectively) Up to 92% of female not have comprehensive knowledge on HIV/AIDS The proportion of respondents having comprehensive knowledge on HIV/AIDS at age groups only oscillate from between 11% to 18%, in details, 16% at 15-19 age group, 18% at 20-24 age group, 11% at 25-29 and 30-34 age group, 17% at 35-39 age group and 14% at 40-44 and 45-49 age group The proportion of people who have not had comprehensive knowledge of HIV/AIDS at age groups is over 82% The proportion of respondents having comprehensive knowledge on HIV/AIDS among never-married group is higher than ever-married group (26% and 14% respectively) The proportion of respondents having comprehensive knowledge on HIV/AIDS among primary and higher education is also higher than the respondents without education (18% and 10% respectively)

Up to 90% of respondents without education not have comprehensive knowledge on HIV/AIDS 20% of respondent who read daily newspaper at least times per week having comprehensive knowledge on HIV/AIDS and 18% of respondents who read newspaper less than times per week having comprehensive knowledge The proportion of respondents who listen to radio at least times per week having comprehensive knowledge on HIV/AIDS is higher than the proportion of respondents who listening to radio less than times per week (18% and 11% respectively)

The proportion of respondents who listen to radio less than times per week not having comprehensive knowledge is quite high (89%) Similarly, the proportion of respondents who watching television at least times per week having comprehensive knowledge on HIV/AIDS is higher than the proportion of respondents who watching television less than times per week (18% and 10% respectively) Especially, up to 99% of respondent who cannot communicate in Vietnamese language not have comprehensive knowledge on HIV/AIDS while only 1% of respondents have comprehensive knowledge The proportion of respondents who can communicate in Vietnamese language having comprehensive knowledge on HIV/AIDS is noticeably higher than the proportion of respondents who cannot communicate in Vietnamese language (23% and 1% respectively)

3 Impacts of mass media exposure and language barrier on comprehensive HIV/AIDS knowledge

To examine the impacts of mass media exposure and language barrier on comprehensive knowledge of HIV/AIDS as stated in the research objective, binary logistic regression, in which level of HIV/AIDS knowledge was treated as outcome variable (dichotomous in nature: 1=comprehensive and 0=non-comprehensive) and mass media exposure, language barrier, socio-demographic characteristic as predictor variables, is the most appropriate method in this study Based on Chi-square’s result, two predictor variables including age and frequency of reading daily newspaper have been dropped out of the model of regression because both of them and HIV/AIDS knowledge are not significantly associated Two models are used to predict level of HIV/AIDS knowledge among “Dzao” ethnic minority in Yen Bai province Model considered the effect of socio-demographic characteristics (sex, marital status and education level) on HIV/AIDS knowledge only, whereas Model focused on effect of mass media exposure and language barrier on level of HIV/AIDS knowledge when controlled for socio-demographic characteristics For these analysis, if levels of significance is 0.05, it was considered as statistically significant

In Model 2, mass media exposure and language barrier were included in order to examine the net effects of them on having comprehensive knowledge on HIV/AIDS when controlled for socio-demographic characteristics However, when examining the multi-collinearity between independent variables in the model of having comprehensive knowledge on HIV/AIDS including main independent variables and control variables, the result showed that there is one correlation that is higher than 0.65 It means that there is multi-collinearity between language barrier variable and education level variable in this model In the other hand, language barrier variable and education level variable have strong association (multi-collinearity = 0.78)

Therefore, it will need to drop out the education variable In model 2, it is found that language barrier was significantly associated with HIV/AIDS knowledge The people who could communicate in Vietnamese language were 2.8 times more likely to have comprehensive knowledge on HIV/AIDS than the people who could not communicate in Vietnamese language (p<0.001) The people who listen to radio at least times per week were 1.1 times more likely to have comprehensive knowledge on HIV/AIDS than the people who listen to radio less than times per week The people who watch television at least times per week were 1.3 times more likely to have comprehensive knowledge on HIV/AIDS than the people who watch television less than times per week However, both of them are not statistical significant at 0.05 level In total Model explains for 8% variation of having comprehensive knowledge on HIV/AIDS when considering on mass media exposure and language barrier, when controlling for socio-demographic characteristics (p<0.001) It means that mass media exposure and language barrier increase 4% explanation of having comprehensive knowledge on HIV/AIDS variation (8% and 4%)

IV Discussion

Similar to the findings from previous studies (Thang et al., 2001; Sarkar, 2009), a major proportion of “Dzao” ethnic minority had low education, even 52% of respondents have no education and most of them have ever married (93%) in this study Majority of respondents are within the age of 15 to 34 Knowledge on HIV/AIDS among ethnic minorities found in this study is very low, which is also similar to other studies (UNFPA, 2007; UNICEF Thailand, 2007) In this study, only 14% of them have comprehensive knowledge on HIV/AIDS

Findings from this study reconfirm previous conclusions that lack of knowledge of HIV/AIDS due to language barrier (Jirakun et al., 1993) A report on Migrant Lao Women also mentioned that mostly ethnic minorities living in rural areas and cannot speak Lao, therefore, HIV/AIDS information is focusing in the city and school only In this study, language is also barrier for ethnic minority as access to HIV/AIDS information radio, television and especially to have comprehensive knowledge on HIV/AIDS is difficult because most of them cannot communicate in the Vietnamese language The proportion of respondents who can communicate in Vietnamese language and have ever heard about HIV/AIDS and who especially had comprehensive knowledge on HIV/AIDS is higher than the proportion of respondents who cannot communicate in Vietnamese language The respondents who can communicate in Vietnamese language are more likely to have comprehensive knowledge on HIV/AIDS than the respondents who cannot communicate in Vietnamese language In addition, Peruga et al (1993) mentioned in their research that no study found significant differences in HIV/AIDS knowledge between married and unmarried respondents in general population In this study, there is not also statistical significant associated between marital status and HIV/AIDS knowledge

television in Vietnamese language Therefore, if respondents even often listen to radio and watch television in their local language, they cannot get enough information to have comprehensive knowledge on HIV/AIDS This unexpected result reconfirmed the important role of language in dissemination campaigns and, particularly the inability of ethnic minority to communication in Vietnamese language

V Conclusion and Recommendation

The key finding from this research are that there is only a unique and important factor which affect comprehensive HIV/AIDS knowledge That is language barrier, particularly the ability of communication in Vietnamese language The people who could communicate by Vietnamese language were 2.8 times more likely to have comprehensive knowledge on HIV/AIDS than the people who could not communicate by Vietnamese language (p<0.001) Other factors such as socio-demographic characteristics and mass media exposure are not significant associated with level of HIV/AIDS knowledge In conclusion, language barrier is the factor affecting comprehensive HIV/AIDS knowledge

(1) Strengthen the Vietnamese language ability of the ethnic minority population. In order to strengthen linguistic ability, the Government should have strategy on universalizing education for ethnic minorities first and foremost At that time, strengthening HIV/AIDS knowledge is the duties of not only the health sector but also related sectors such as education Additionally, ethnic minority group are very poor, therefore, authorities should develop a network including volunteers, peer educators, collaborators to organize Vietnamese language classes for these groups;

(2) Intervention programmes should focus on communication strategy The communication strategy should use diverse modes such as through television, radio, newspaper, leaflets, posters and group meetings at communes Target groups can include illiterate people, pupils, other general population groups Due to language barrier, communication materials should be designed in both local language and Vietnamese language Because the rate of illiteracy among Dzao ethnic minority is quite high, communication materials should be pictorial for easy understanding

References.

Lao PDR (2009) Alternative Report - The Situation of Migrant Lao Women in Thailand and Their Vulnerability to HIV/AIDS The Committee on the Elimination of Discrimination against Women -44th CEDAW Session. Retrieved March 21, 2010 from

Jirakun, A., Vickery, L., Brown, K., Chumui, D., Pornsakunpaisan, K., & Sanae, A (1993) Risk factors to HIV infection among ethnic minorities (EM) in north Thailand International Conference on AIDS Retrieved March 18, 2010

Population Council (2007) Changing transitions to Adulthood in Vietnam’s Remote Northern Uplands: A focus on Ethnic Minority Youth and their Families Retrieved April 15, 2010

Sarkar, P (2009) Information and Knowledge about HIV/AIDS: Bangladesh context International Journal of Molecular Medicine and Advance Sciences, 5(1-4), 10-14

Thang, D B., Chi, K P., Thang, H P., Long, T H., Thich, V N., Thang, Q N & Detels, R (2001) Cross-sectional study of sexual behavior and knowledge about HIV among urban, rural, and minority residents in Viet Nam Bulletin of the World Health Organization, 79, 15–21

UNFPA Vietnam (2007) Knowledge and Behavior of Ethnic minorities on Reproductive Health.

Sexual and Reproductive Health Services and HIV Prevention for Sex Workers

Chaiyos Kunanusont, MD, MPH, MS, PhD (Epidemiology) HIV/AIDS Adviser, UNFPA Asia Pacific Regional Office Background

Globally sex workers have inadequate access to HIV prevention services, and it is believed that their access is even more limited for appropriate treatment, care and support To date, the HIV response has devoted insufficient attention and resources to efforts to address HIV and sex work, with less than 1% of global funding for HIV prevention being spent on HIV and sex work The UNAIDS 2008 Report on the Global AIDS Epidemic reports that 60.4% of sex workers were reached with HIV prevention services (defined as the proportion who know where they can receive an HIV test and have received condoms in the past 12 months) The 2006 Annual Review the International AIDS Alliance states that globally only 16% of sex workers have access to basic HIV services Recent studies continue to confirm that in many countries sex workers experience higher rates of HIV infection than in most other population groups4.

In Asia and the Pacific region sex work demands a central position in any successful HIV response in the region The reports of the Commission on AIDS in Asia5 and Commission on AIDS in the Pacific6have been fundamental to the recognition of sex work as a central driver of the HIV epidemic in the region The Asia report calculates that up to 10 million women in Asia sell sex to an estimated 75 million men, who in turn have intimate relations with a further 50 million people However, HIV prevention coverage reaches only one third of all sex workers in the region and programmes to reduce the demand for unprotected paid sex are inadequate

Major content

Evidence suggests that HIV interventions in the sex industry are more effective when sex workers themselves have direct ownership in designing, implementing and monitoring of programs This entails moving beyond standard HIV prevention programmes and addressing the overall health – including sexual and reproductive health - and well being needs of sex workers and their clients while, at the same time, respecting fundamental human rights Sex workers must be recognized as agents of change rather than as “vectors” of infection and this requires a paradigm shift in the way sex workers are viewed and engaged in the response

A human rights based approach should be applied to any HIV program targeting sex workers and their clients The illegality of sex work in most counties in the region creates an environment that facilitates harassment and hinders the delivery of prevention and care Programs must build the capacity of sex workers to engage in advocacy with policy makers to ensure protection of their fundamental rights to safe work, fair wages, reasonable working hours, quality health and social security services The practice of mandatory or coercive STI and HIV testing and lack of confidentiality in programs targeting sex workers in some countries violates human rights The ethical principles of voluntarism and confidentiality should be incorporated into the design, implementation and monitoring and evaluation of all sexual and reproductive health and HIV programs

There are limited health services provided for sex workers, and existing services largely focus on HIV prevention only There are major gaps in provision of sexual and reproductive health services for female sex workers There is a need for improved STI management services As many STIs are asymptomatic, both sex workers and providers often not recognize the need for examination and treatment Many providers are not able, or are unwilling, to diagnose oral and ano-rectal STIs in female, male and transgender sex workers Sex workers are not receiving adequate counseling on which specific services they are able to provide while under treatment for various STIs Some studies have shown higher rates of cervical cancer in sex workers; thus screening to prevent cervical cancer should be included as part of a minimum package of services for sex workers High rates of abortion in sex workers indicate that sex

4 The UNAIDS 2008 Report on the Global AIDS Epidemic.

5Redefining AIDS in Asia; Crafting an Effective Response (2008):

workers are generally not receiving adequate contraceptive services7 Providers should offer sex workers

advice on the range of contraceptive methods available, including back-up methods such as emergency contraception At the same time, there should not be a presumption that sex workers, especially HIV positive sex workers, who become pregnant necessarily opt for an abortion

Sexual and reproductive health services for sex workers should be tailored to their needs and delivered in a supportive and non-judgmental manner A comprehensive rights-based package of services for female, male and transgender sex workers should be developed and implemented in partnership with sex workers and should include at a minimum

(a) sex worker-driven prevention efforts including peer education and access to male and female condoms and water-based lubricants,

(b) a comprehensive package of sex worker-friendly health information and services including STI management, VCT, and reproductive health (including contraception, maternal health care, abortion and post abortion care, and cervical cancer prevention),

(c) appropriate counseling and services for HIV-positive sex workers on contraception and pregnancy, including antenatal care, prevention of parent-to-child transmission, and ARV treatment, care and support,

(d) services that address the sexual health needs of transgender sex workers, including hormone treatment,

(e) access to a range of related services including harm reduction (clean needles and syringes), drug and alcohol programs, mental health and social support services, including sex worker community groups Services for sex workers need to be accessible (appropriate locations and timings), acceptable, and affordable to all sex workers Sexual and reproductive health services should be closely linked to peer education programs and other interventions to ensure that they are promoted Specific outreach should take place to reach non-brothel based sex workers, minority sex workers and other more vulnerable sex workers including younger sex workers

Lessons learned

Clear policies are needed ensuring delivery of HIV/STI services is incorporated within RH programmes Once policies are in place, management by all relevant stakeholders can assist with revising service delivery e.g addition of HIV/STI counseling and testing into busy RH clinic schedules Coordination is needed for monitoring quality of services, workloads and any gaps in integrated service provision Providing staff incentives such as professional development opportunities, compensating for overtime and employment of new staff such as lay counselors can also assist

Community mobilization is also important to go hand in hand with improved service delivery Advocacy with community can assist increase uptake of linked services, reduction of stigma associated with HIV/STI testing and treatment, and acceptance of HIV/STI care within traditional RH settings Linkage opportunities exist within a range of specialist and centralized core services such as management of sexually transmitted infections (STIs), and also via local primary health care centres Appropriate levels of training, support and referral are required to achieve both horizontal and vertical linkages in order to deliver more comprehensive and holistic services to sex workers, clients and partners

Access to good quality condoms and water-based lubricants is essential for HIV prevention Policy and programs must be focused on making condoms accessible and affordable to all sex workers and their clients Laws, regulations and practices that penalize possession of condoms should be changed Cultural and other barriers that limit access to and use of condoms by sex workers and their clients need to be addressed While many countries have put in place condom distribution programs, there remains a problem of lack of supply Failure to include sex worker organizations and sex workers in the design, implementation and evaluation of these programmes further results in lack of access and use of the condoms that are available In addition, condom distribution programs often include only male condoms, and this may serve as a barrier to use them because of an often unequal power relationship between sex workers and their clients

7Morineau G, Neilsen G, Sopheab H, Chansy P, Mustikawati DE Falling through the cracks: addressing the reproductive health needs of

Rapid situation and response assessment of HIV programs for men who have sex with men

Authors:

Nguyen Thi Minh Tam – Harm Reduction Department (VAAC) David Lowe – International consultant

Pham Vu Thien – National consultant Nguyen My Linh – UNAIDS

Nguyen Hong Hai – VAAC Mac Thi Ngoc Mai - VAAC

SUMMARY

In response to the increasing HIV prevalence among MSM, the Viet Nam Administration for HIV/AIDS Control (VAAC) and UNAIDS commissioned a Rapid Situation and Response Assessment (RSRA) of HIV and programs for MSM to inform the development of the national guidelines for MSM-focused HIV programs

According to Integrated Behaviour and Biological Surveillance (IBBS) data of 2005 and 2009, HIV prevalence rates among men having sex with men (MSM) had increased significantly from 9.4% to 17.3% in Ha Noi and from 5.3% to 14.8% in Ho Chi Minh City Risk behaviors that could lead to further increases in HIV prevalence among MSM were also clearly documented by these studies Primarily these are high numbers of sexual partners, low levels of consistent condom use, and high levels of drug use (injecting and non-injecting) HIV programs for MSM only exist in a small number of provinces, and where programs exist, coverage has been insufficient to halt the increase in HIV prevalence

Key findings of the rapid assessment point to the need for an enhanced and scaled-up response to HIV and sexually transmitted infections (STIs) among MSM in Viet Nam, supported by National Guidelines

I. BACKGROUND

The term ‘men who have sex with men’ (MSM) is used as a behavioural term to refer to biological males who have sex with other biological males, regardless of sexual orientation or gender identity While MSM make up a relatively small proportion of the total population, HIV prevalence among MSM can make up a significant proportion of the total HIV epidemic The Asian Epidemic Model, used by the Commission on AIDS in Asia, projects that unless effective prevention measures are intensified, by 2020 around 46% of new HIV infections in Asia will be among MSM, up from 13% in 2008

The 2005-2006 IBBS found HIV prevalence among MSM of 9.4% in Ha Noi and 5.3% in Ho Chi Minh City A second IBBS conducted in 2009 found that HIV prevalence among MSM had increased significantly to 17.3% in Ha Noi and to 14.8% in Ho Chi Minh City This rapid rise in prevalence reflects a similar pattern of significant increases in HIV infection in major urban centres in other Asian countries

In recognition of the need for building and strengthening interventions to address HIV-related vulnerabilities and risks of MSM, the Viet Nam Administration for HIV/AIDS Control conducted a Rapid Situation and Response Assessment (RSRA) of HIV and AIDS programs for MSM which has informed the development of the national guidelines for MSM-focused HIV programs

II AUDIENCESANDMETHODOLOGY

The main research methods of this assessment were a desk review of documents, in-depth interviews and focus group discussions

Relevant Vietnamese documents on the situation and response to HIV among MSM were reviewed International documents were also reviewed, primarily from the region, with a focus on best practice and programmatic approaches, the elements of a comprehensive approach and key lessons learned

representatives from civil society organisations, UN agencies and donors Seven focus group discussions were held with self-identified MSM, male sex workers and transgender people in Hanoi and Ho Chi Minh City and staff in charge of MSM programs in six provincial AIDS centres

III RESEARCHOUTPUT

MSM is a diverse population Social research reveals that MSM in Viet Nam are not a single identifiable group and they not have a unique profile MSM include a variety of sub-populations such as men who identify themselves as homosexual, bisexual and heterosexual, and transgender people who identify themselves as women There is evidence of MSM in both urban and rural areas

The IBBS data has clearly indicated an increase in HIV prevalence among MSM from 2005 to 2009 To gain a better understanding about the factors which contribute to this rise, the assessment examines the extent of how each element in the comprehensive package of service has been established in Viet Nam to respond to the needs of MSM and transgender people

Coverage of peer outreach and drop-in-centre (DICs): Total MSM contacts for peer education and DIC visits in 2009 by projects funded through FHI and Pact in six provinces were 23,943 Based on the estimates of Viet Nam’s MSM population developed for the most recent HIV estimates and projections, this represents coverage of 19% in these six provinces On a national basis, peer education and DIC contacts in 2009 represented coverage of 5%

Condoms and lubricant: Distribution and social marketing of condoms and lubricants which specifically targets MSM is restricted to a small number of provinces who are implementing HIV interventions with this population They include Ha Noi, Hai Phong, Da Nang, Khanh Hoa, Ho Chi Minh City and Can Tho

Volunteer counselling and testing (VCT) and STI utilisation: Overall coverage is still very low In 2009, FHI MSM projects made a total of 11,170 referrals to VCT, representing 62% of the number of MSM reached A total of 2,477 MSM (22%) used the referrals FHI MSM projects referred 9,142 MSM to STI services, which was 51% of the total number of MSM reached but only 2,023 MSM, or 22% of those reached, used their referral

Comprehensive prevention package available but coverage is low: The full range of prevention services that make up the prevention component of the comprehensive package of services are being provided in provinces where HIV programs for MSM have been established as mentioned above However, there is insufficient emphasis on interventions that address the increased HIV risk that result from injecting drug use and alcohol consumption Coverage of prevention services within those provinces with MSM HIV programs is too low, intensity and frequency of contact with MSM is insufficient, and there are no HIV prevention programs for MSM in other provinces

Care, support and treatment: MSM are reported to have good, non-discriminatory access to HIV care, support and treatment services, although there is insufficient data to determine the extent to which HIV-positive MSM act on referrals to these services

Strategic information on MSM is still limited MSM have been included in the Integrated Behaviour and Biological Surveillance, but not yet in the annual sentinel surveillance Because there has been no national study to estimate the number of Vietnamese men who have sex with other men, most organisations have to use the HIV/AIDS estimates and projections for 2007-2012 to guide their work

IV DISCUSSION

The MSM community is diversified and each sub-population has different social characteristics and sexual health needs HIV prevention programs directed at a single sub-population are likely to reach only a small proportion of MSM This needs to be taken into account in the design and delivery of programs targeting MSM

where MSM interventions not currently exist

There is a need for MSM Clubs, VCT and STI services to ensure that referral systems are working effectively by monitoring the extent to which HIV-positive MSM are acting on referrals and by addressing any barriers that may exist A continuum of prevention to care, support and treatment needs to be achieved through substantive and interactive relationships between HIV programs for MSM and HIV care, support and treatment services As it is likely that most MSM who are HIV-positive not know their status, they are not in a position to receive the benefits of early HIV treatment Efforts to increase HIV testing among MSM are clearly a high priority

Stigma against male-to-male sex in Viet Nam is high and results in discrimination against MSM and transgender people Stigma and discrimination impairs the effectiveness of HIV prevention programs as it drives MSM underground, creating difficulties for prevention programs in reaching them It also makes MSM reluctant to access HIV counselling and testing and STI services Reducing stigma and discrimination against MSM and transgenders is essential for ensuring the success of HIV programs for MSM and should be a high priority for all sectors involved in the HIV, AIDS and STI response for MSM

V. RECOMMENDATIONS

The legal and policy frameworks for HIV programs for MSM are very supportive The legal, policy and planning documents of the Government of Viet Nam recognise the importance of HIV programs targeting MSM, as one of the key populations at higher risk This provides a supportive framework for the scaling-up of responses to address the vulnerabilities of MSM to HIV

Yet current resources for HIV programs for MSM are insufficient to mount a response sufficient to avert a significant increase in HIV prevalence Efforts need to be made to increase the allocation of national and local level funding and to broaden the donor base for funding

A comprehensive approach to controlling HIV among MSM includes foundational activities to create an enabling environment, a full range of prevention interventions, access to the full range of care support and treatment services, strategic information to guide and monitor program development, and other supportive interventions such as capacity building and organisational development This comprehensive approach will be adopted by VAAC for HIV prevention and control among MSM

Reference

ASEAN, UNDP, UNAIDS, WHO, UNESCO, USAID & APCOM (2009) Developing a Comprehensive Package of Services to Reduce HIV among Men who Sex with Men (MSM) and Transgender (TG) Populations in Asia and the Pacific, Regional Consensus Meeting

Commission on AIDS in Asia (2008) Redefining AIDS in Asia - Crafting an Effective Response, Report of the Commission on AIDS in Asia

Family Health International (2010) Results from the HIV/STI Integrated Biological and Behavioural Surveillance (IBBS) in Viet Nam 2009-2010 (unpublished)

Ministry of Health – VAAC (2009), Viet Nam HIV/AIDS Estimates and Projections, 2007-2012 Ministry of Health – VAAC (2007), Results from the HIV/STI Integrated Biological and Behavioural Surveillance (IBBS) in Viet Nam 2005-2006

FACTORS ASSOCIATED WITH ILLICIT DRUG USE IN PATIENTS ON METHADONE MAINTENANCE THERAPY IN VIETNAM Authors: Nguyen To Nhu1; Nguyen Thanh Long2; Tran Vu Hoang1; Rachel Burdon1;

Tran Thi Thanh Ha1; Chi Nguyen1; Stephen J Mills1 Nguyen Thi Minh Tam2;

Pham Duc Manh 2; Nguyen Quynh Mai2; Le Truong Giang3; Tieu Thi thu Van3;

Vu Van Cong4; Kevin Mulvey5; Elissa Mangolin6; Nguyen Thi Minh Ngoc6

(*) Presenting author

1 Family Health International, Vietnam

2 Vietnam Administration of HIV/AIDS Control, Ministry of Health 3 Provincial AIDS for HIV/AODS Control Committee, Ho Chi Minh City 4 Provincial HIV/AICS Control Center, Hai Phong city

5 SAMHSA, PEPFAR Vietnam

6 US Agency for International Development (USAID), Vietnam country office

I Background: Vietnam is experiencing an HIV epidemic which is concentrated in populations with high-risk sexual and injecting drug practices Given the central role of IDU in the spread of HIV, the MoH has implemented a range of HIV prevention interventions in Vietnam since the mid 1980’s In 2006 the Vietnam Administration of HIV/AIDS Control (VAAC) began working with international organizations and other stakeholders on a methadone maintenance therapy (MMT) pilot in Hai Phong and Ho Chi Minh City (HCMC), where the IDU populations are mostly heavily affected by HIV The objectives of the MMT pilot are to reduce the transmission of HIV and related infections among opioid drug users; 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 Six pilot methadone clinics were established in 2008 under the auspices of the Ministry of Health (MOH) and another 11 sites have since been opened Treatment in all of the methadone clinics is paid for by government funding and admission is through a referral process An evaluation of the methadone programs was conducted by the Vietnamese Administration of HIV/AIDS Control (VAAC) to examine and document outcomes, impact and cost-effectiveness of the MMT pilot in collaboration with international organizations and stakeholders including PEPFAR, FHI, HPI, WHO, and the Hanoi School of Public Health This abstract uses data from the prospective cohort study , one of the three components of the MMT evaluation to explore factors associated with heroin use at month follow-up

and other variables that can confound the heroin use (outcome variable) 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

Baseline Results: The median age for the study population was 30 years (range, 16.6 to 58), the majority were male (95%) Most patients had a low education level, with only 56% completing secondary education and less than 5% having college or university education A total of 64% of the study population reported being employed, with only 11 percent being steadily employed at the time of the study, Approximately 98 percent of study participants in Hai Phong and 79 percent in HCMC had their own income and the average monthly income was about VND 6.9 million ($365) Nearly 41 percent of participants said that they had been involved in crime (apart from illegal drug use) to support their drug use On average, participants had started using drugs by age 21 and 50 percent had started before 20 The most common primary drug at first use was heroin (88%), followed by opium (9%)

Results over Time: Overall, 90% of patients in the study were retained on methadone treatment at months At nine months, 94 patients had stopped treatment including who had died The key reason for stopping treatment was being sent to a mandatory drug rehabilitation center, especially in HCMC Most patients showed strong adherence to MMT with the rates of missing a dose for five days or more being extremely low (2.3% at months and 0.9% at months) Illicit opioid drug use was 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 The proportion of patients with at least one positive urine test reduced over time, from 100% at baseline to 27.5% at months, 19.4% at months and 18% at months Table demonstrates a significant reduction in heroin use reduction over time which is extremely impressive, especially when compared to other studies of MMT outcomes in different international settings

Figure: Illicit opioid use over time at baseline, 3, 6, and months

Of those, who continued using drugs, the proportion who injected drugs reduced from 87% before MMT to 56% at months Needle sharing in the month before interviews was very low, with only one individual reporting sharing needles with other injectors during the months of MMT

We examined factors associated with illicit opioid drug use by binary analysis and found that these included being unemployed (OR= 1.51, p=0.02), a high methadone dose (OR= 1.63, p=0.04), ongoing ARV treatment (OR= 1.42, p=0.08); and received treatment in Hai Phong (OR=2.09, p<0.01) After controlling for demographic characteristics, including age, gender, duration of using drugs before treatment, and frequency of heroin use, the affects of above four factors on drug use status were still significant The multivariate analysis also detects the interaction between methadone dosage and ARV status (OR= 2.3, p=0.04)

Table Factors associated with illegal use of heroin at month follow-up

Related factors Crude Risk Ratio Adjusted Risk Ratio

95% confidence interval 95% confidence interval Age at treatment

Increase by every age 0.99 (0.97 – 1.02) 0.99 (0.96-1.02)

p-value 0.89 0.37

Gender

Male vs Female 1.45 (0.60 – 3.49) 1.10 (0.44-2.75)

Time of heroin dependence/use

Increase by the year 1.02 (0.98 – 1.06) 1.00 (0.96-1.04)

p-value 0.33 0.90

Frequency of using heroin before treatment

Increase by every time used per day 1.04 (0.92 – 1.16) 1.04 (0.91-1.18)

p-value 0.57 0.56

Methadone dosage at 9th month

≤ 60mg 1.00

61- 120 mg 0.82 (0.52 – 1.27)

1.17 (0.84-1.61)

> 120mg 1.63 (1.03 -2.58)

p-value 0.37 & 0.04 0.35 HIV status

Yes vs No 1.50 (1.02 – 2.19)

p-value 0.04

On ARV therapy vs Not on ARV therapy 1.42 (0.96-2.08) 2.34 (1.03 – 5.29)

p-value 0.08 0.04

Current employment status

Not employed vs Employed 1.51 (1.06 – 2.15) 1.61 (1.11-2.33)

p-value 0.02 0.01

Having support from family members

Yes vs No 0.97 (0.48 – 1.96)

p-value 0.92

Had conflict with family members

Yes vs No 0.88 (0.56 – 1.37)

p-value 0.56

Frequent alcohol consumption

Yes vs No 1.03 (0.86 – 1.23)

p-value 0.75

Cigarette Smoking

Yes vs No 0.91 (0.37 – 2.26)

p-value 0.84

City

Hai Phong vs HCMC 2.09 (1.46 – 3.00) 2.67 (1.76-4.05)

p-value <0.01 <0.01

Social support

Good vs None/little 0.59 (0.34 – 1.02)

p-value 0.06

It is possible that not all clients on these ARV drugs received high enough doses of methadone to control withdrawal and cravings which explains why they are more likely to be continuing to use heroin over time

Employment status was found to be associated with ongoing heroin use at months It is plausible that those who are most stable on MMT and not continuing to use heroin are those who are most likely to seek and hold regular employment Community re-integration and employment is one of the key outcomes of the MMT program and thus the importance of connecting MMT patients with vocational and employment program is critical to the successful outcomes of this pilot It is also interesting to note that having good social support appears to be protective against ongoing heroin use although this was not statistically significant The difference in use of heroin at months between Hai Phong and HCMC can be partly explained by the fact that MMT clients not on ART in Hai Phong had a lower average MMT dose compared to clients in HCMC A contributing factor could be that the Hai Phong program did not have urine tests from January to September 2010 to guide MMT dosing for those continuing to use heroin

CLIENTS OF FEMALE SEX WORKERS AS A BRIGING POPULATION

IN VIETNAM

Nhu T Nguyen1; Hien T Nguyen2; Stephen J Mills.1, Huan Q Trinh3; Roger Detels.4

1Family Health International, Vietnam Country Office, Hanoi, Vietnam 2National Institute of Hygiene and Epidemiology, Hanoi, Vietnam 3 Ministry of Health, Vietnam

4Dept of Epidemiology, School of Public Health, University of California, Los Angeles

Introduction: Understanding the bridging behavior of clients of female sex workers (FSWs) is important for projecting and intervening in the spread of sexually transmitted infections and HIV in Vietnam The goals of this study were to determine HIV/STI prevalence amongst different bridging groups, identify factors associated with being a potential or an active bridger, and assess the association of drug use and unsafe sex with HIV and/or STI prevalence Thus far, bridging behavior among male clients of FSWs in Vietnam have not been adequately studied Only one study has targeted male clients of FSWs who were sampled from public sexually transmitted infection (STI) clinics in Vietnam, which represented the subgroup having unprotected sex with high-risk women (Thuy et al., 1999)

The goals of this study were to determine HIV/STI prevalence amongst different bridging groups, identify factors associated with being potential and active bridgers, and assess the association of drug use and unsafe sex with HIV and/or STI prevalence Knowing the STI prevalence of FSWs’ clients is important There is substantial biological evidence demonstrating that persons affected with STIs are more likely to both acquire and transmit HIV infection Syphilis and herpes simplex type (HSV-2) serology in addition to HIV, were included as outcomes of this study

Methods:

Subjects and Procedures: In April, 2007, 292 male clients visiting FSWs at sex venues in Hai Phong City and Do Son Beach were interviewed in a cross-sectional survey, using two-stage time-location cluster sampling In the first stage, peer educators and sex venue collaborators mapped sex venues in Do Son Beach and the Thien Loi area of Hai Phong, which is where more than 90% of local sex workers in Hai Phong City are located (Nguyen et al., 2005) Sex venues included places of entertainment, such as hotels, motels, guest houses, café bars, and karaoke bars, which have rental rooms available for FSWs and their clients Since client numbers vary by time of day, the average number of male clients in each time slot (i.e., weekday nights, weekend afternoons, and weekend nights) was obtained In the second stage, five male clients were consecutively interviewed from the selected cluster, where they rented rooms for sexual encounters A total of 146 clients in Do Son Beach and 146 in the Thien Loi area participated Inclusion criteria were men aged 18-60 years who had (within the past year) or were about to have sex with a FSW at a selected sex venue during the selected time slot, and were fluent in the Vietnamese language Male clients were initially asked by sex venue owners or pimps to participate Clients expressing an interest were then taken to a rented interview room on-site and were screened for eligibility The interview was administrated by a CD player and earphones in an anonymous manner, using a pre-tested structured questionnaire A corresponding answer sheet with no identifying information was designed for simplicity and ease of use by clients It was checked for completeness by the interviewer After the interview, five ml of venous blood was drawn, or if a client was unwilling to donate blood, oral fluid was tested for HIV

(IRB) and the National Institute of Hygiene and Epidemiology (NIHE) Ethical Review Board

Statistical Analysis: Data were double-entered and converted to STATA version 9.2 for analysis The bridging variable was created by compiling condom use with high-risk women (FSWs; always condom use vs not always condom use) and low-risk women (always condom use vs not always condom use), and classifying male clients into unlikely, potential, and active bridgers Active bridgers

had sex with both high- and lower risk sex partners during the same time period and did not consistently use condoms with either type of partner, potential bridgers had sex with both high- and lower risk sex partners during the same time period and always used condoms with high-risk sex partners but not with low-risk partners, and unlikely bridgers always used condoms with both groups or always used condoms with FSWs and had no lower risk sex partners Logistic regression was used to assess the association of the bridging variable with HIV and/or syphilis and HSV infection and adjusted for age, education, and income

Table shows the single and joint associations of unprotected sex upon the likelihood of being HIV- and/or syphilis-seropositive The joint adjusted odds ratio was 14.4 (95% CI 3.9-53.3) higher than the additive of the two (5.2 + 2.8 - 1) – synergy

Vietnam than studies using interviewer-administered strategies

Study Limitations: There was a relatively high proportion of refusals in the study (participation was 75%) resulting in potential selection bias The study is also subject to social desirability bias, which could result in over-reporting of condom use Although 94.5% of the population reported having always used condoms with FSWs, when asked if they had used a condom with a FSW during their last sexual encounter, only 84.9% reported doing so (95% CI 79.5%-90.2%) If there was similar over-reporting of condom use with wives/girlfriends, the study would be subject to misclassification of bridging groups This bias, however, would reduce the probability of observing a difference, and was therefore a conservative bias

Conclusions: Almost 60% of male clients of sex workers in Hai Phong may be transmitting HIV and/or STIs to their non-commercial sex partners A high proportion of clients were infected with HSV-2, which increases the risk of acquiring HIV and subsequently transmitting it to their low-risk partners Their attitudes about condom use demonstrate that current intervention methods are ineffective Thus, there is a need for more effective condom promotion activities to reach this group of probable core transmitting bridgers The observed synergistic interaction between condom slippage/breakage and drug use emphasizes the need for condom promotion and education campaigns that target drug users, especially with messages about proper condom use Instruction about proper condom use should be an essential component of drug substitution treatment and needle and syringe exchange programs, in addition to other intervention programs for drug users Quality of condoms should be strictly controlled and water-based lubricant to be distributed to minimize condom breakage

References

Ariawan, I., & Frerichs, R.R.(1996) CSurvey 1.5 A cluster sampling utility program for IBM-compatible microcomputers UCLA

Brown, J.M., Wald, A., Hubbard, A., Rungruengthanakit, K., Chipato, T., Rugpao, S., et al (2007) Incident and prevalent herpes simplex virus type infection increases risk of HIV acquisition among women in Uganda and Zimbabwe AIDS (London, England), 21(12), 1515–1523 Medline

doi:10.1097/QAD.0b013e3282004929

del Mar Pujades Rodriguez, M., Obasi, A., Mosha, F., Todd, J., Brown, D., Changalucha, J., et al (2002) Herpes simplex virus type infection increases HIV incidence: a prospective study in rural Tanzania AIDS (London, England), 16(3), 451–462 Medline doi:10.1097/00002030-200202150-00018

Duong, C.T., Nguyen, T.H., Hoang, T.T., Nguyen, V.V., Do, T.M., Pham, V.H., et al (2008) Sexual risk and bridging behaviors among young people in Hai Phong, Vietnam AIDS and Behavior, 2(4), 643–651 doi:10.1007/s10461-007-9265-0

Gorbach, P.M., Sopheab, H., Phalla, T., Leng, H.B., Mills, S., Bennett, A., et al (2000) Sexual bridging by Cambodian men: potential importance for general population spread of STD and HIV epidemics Sexually Transmitted Diseases, 27(6), 320–326 Medline doi:10.1097/00007435-200007000-00004

Jennings, J.M., Luo, R.F., Lloyd, L.V., Gaydos, C., Ellen, J.M., & Rietmeijer, C.A (2007) Age-bridging among young, urban, heterosexual males with asymptomatic Chlamydia trachomatis Sexually Transmitted Infections, 83(2), 136–141 Medline doi:10.1136/sti.2006.023556

Lama, J.R., Lucchetti, A., Suarez, L., Laguna-Torres, V.A., Guanira, J.V., Pun, M., et al., & Peruvian HIV Sentinel Surveillance Working Group (2006) Association of herpes simplex virus type infection and syphilis with human immunodeficiency virus infection among men who have sex with men in Peru The Journal of Infectious Diseases, 194(10), 1459–1466 Medline doi:10.1086/508548

Liu, H., Xie, J., Yu, W., Song, W., Gao, Z., Ma, Z., et al (1998) A study of sexual behavior among rural residents of China Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 19(1), 80–88 Medline

Rothman, K.J., & Greenland, S.(1998a) Concepts of Interaction In Modern Epidemiology New York: Lippincott Williams & Wilkins, pp 341, 342

Sexual Risk Behaviours among Male Migrant Freelance Labourers in Urban Vietnam: Prevalence and Correlates

Nguyen Van Huy1, 2 (0917.363.919), Michael P Dunne2, Joseph Debattista3,

Nguyen Tran Hien1,4 & Dao Thi Minh An1

1Faculty of Public Health, Hanoi Medical University, Vietnam

2School of Public Health, Faculty of Health, Queensland University of Technology, Australia 3Brisbane Sexual Health & HIV Service, MetroNorth Health Service District, Australia

4National Institute of Hygiene and Epidemiology, Vietnam

ABSTRACT

Like many other developing countries, Vietnam is experiencing an increasing wave of rural-urban migration This process of migration, whether voluntary or not, may result in the spread of HIV infection both to those who migrate and to members of the communities that receive migrants This study examined self-reported risk behaviours among 450 male migrant freelance labourers in urban Hanoi, Vietnam, in 2009-2010 Risk of acquiring or transmitting HIV and other Sexually Transmitted Infections (STI) was high among these men One third of the sample reported having intercourse with commercial sex workers and one quarter had casual sex partners Approximately one in every 12 men reported homosexual or bisexual behaviour The men on average had partners within the preceeding year In general, condom use was inconsistent These men have limited HIV knowledge and only moderate motivation and perceived behavioural skills for protective behaviour The study provides strong evidence for preventive further interventions To be effective, a comprehensive public health approach tailored to the specific needs and vulnerabilities of these men should be applied It is important to include such factors as the pervasive peer influence to ‘live dangerously’, persistent myths about low risk from sex with people who look healthy or with casual partners not classified as ‘sex workers’ and the low group norms for HIV prevention motivation

Key words: Vietnam; Migrant Labourer, HIV/AIDS; IMB Model; Sexual Behaviour; Sexual Risk Behaviour

INTRODUCTION

Most previous studies of HIV risk behavior in Vietnam have focused on traditional “core transmitter” groups (Agence France-Presse, 2001; N T Hien, 2002; N.T Hien, Long, & Huan, 2004; Tuan et al., 2007; Vietnam Commission for Population Family and Children, 2003) However, this concentration on high risk groups may leave others under-protected or unprepared for prevention For male migrant workers, the separation from family, breakdown of social networks, lack of social controls and support and anonymity of living in a city make them especially vulnerable to HIV infection These men may have multiple sexual encounters with different, changing partners, and usually without condom protection (Jochelson, Mothibeli, & Leger, 1991), and consequently have higher rates of HIV as compared with non-migrant men (Lurie, Williams, Zuma, Mwamburi, et al., 2003)

Although there is growing interest of research in migrant labourers (Duong, Anh, Hong, Trung, & Bach, 2005), little is known about patterns and determinants of risky or safer sexual behaviours for HIV (N V Huy, Dunne, Debattista, Hien, & An, 2010)

highlighted, however, that as the model has been by and large individual-level based, there is a need to adapt the model in order to assess how other social and individual factors associated with HIV-related preventive behaviours

The main goal of this study was to examine prevalence of HIV risk behaviour and factors associated with risky - or safer - sexual behaviour among male migrant freelance labourers in urban Vietnam To understand factors associated with such a behaviour, we adopted the IMB model with an additional components –consisting of alcohol use, migration index, social connectedness, depression, and access to AIDS information as a basis to examine these associations Our study hypothesized that social structure, information and motivation would be associated with protected sex self-efficacy and this self-efficacy would be associated with the level of safer sex behaviour among male migrant labourers

The current study has been informed by two qualitative sub-studies The first of these illuminated migrants’ life experiences in urban space, including stressors related to physical, financial and social factors among migrant labouring men and the strategies they use to cope with them (N.V Huy, Dunne, Debattista, & An, 2010) The second sub-study explored how social contexts shape HIV risk behaviours (N V Huy, et al., 2010) The current quantitative survey study was carried out as part of a larger, multi-disciplinary project attempting to understand determinants of HIV risks among male migrant freelance labourers in Vietnam

METHOD

Research Site The site for this study is in urban and suburban Hanoi in northern Vietnam Hanoi is one of the two large cities in Vietnam and one of the most frequent choices for rural-urban migrants , including those who become unregistered labourers

Sample Size and Participants Based on a definition freelance labourers by Duong et al (2005) and Simpson and Weiner (1989) participants were males aged 18-59 who work for private owners or self-earn without a labour contract. A sample of 450 was identified given the following formula of (Lwanga & Lemeshow, 1998) for sample surveys of simple random sampling

(Z2

1-α/2 )P(1-P)N

n = -D2 (N-1) + (Z2

1-α/2 )P(1-P)

Where α refers to a statistically significant level at 05; (1-α) is a confidence level (95%); Z yields 1.96, a value derived from the Z-table corresponding to α of 05; P is defined as an estimated population proportion with protected sex (36.2% based on our pilot survey); d is an absolute precision at 04; N is the population size with 5000 as estimated for male freelance workers in Hanoi based on the data of ANU (2003) and Duong et al (2005); n, a minimum sample size according to the formula, is 450

A sampling frame was made by social mapping venues of migrant labourers in districts of Hanoi We aimed to identify as many venues of male migrant labourers within the city as possible A group of researchers were formed and trained on mapping Each member was assigned a number of districts where he or she was expected to visit Afterwards he or she identified venues at which migrant labourers congregated In each district field workers searched for men in casual employments Typically this is in streets, markets, construction sites, bus stations, small business shops, or by such other social services as schools, hospitals, and factories In each venue key informants such as migrant labourers themselves, local people living close to the venue, local leaders, experienced researchers from prior studies on mobile populations, peer educators and outreach officers were consulted for mapping the next venues At the same time, field workers were asked to estimate the number of male migrant labourers as a basis for approaching respondents in the main survey Finally a list of all the venues and the estimated number of respondents was created

approached the entire population to conduct structured interviews

Participants were verbally informed about the study purpose, that participation was voluntary, that they had the right to withdraw at any point, and, that data would be handled confidentially After obtaining informed consent, a structured questionnaire was administered to participants by face-to-face interview The interviews were conducted in participants’ homes, at their worksites, in the home of researchers or a nearby place convenient to participants The survey was conducted by trained interviewers, and no personal identifiable information was recorded on the questionnaire The questionnaire took between 30-45 minutes to complete Each participant was given AU$10 to compensate for his time The study protocol was approved by the Institutional Review Boards at both Queensland University of Technology in Australia and Hanoi Medical University in Vietnam

Measures

Social Structure Access to AIDS information was formed from 12 items (α = 55) The ratio of the number of migratory cities to years of total migration was employed as an index of mobility (Li, Fang, Lin, Mao, Wang, Yang, et al., 2004) Alcohol use was a composite of the number of standard drinks and frequency of use over the past weeks (α = 60) Social connectedness was assessed with items of (Hawthorne, 2006) (α = 74) To measure Depression, a short version “Boston form” of CEDS was used as it is made up of concrete experiences that participants with less formal education could interpret in the context of their daily lives, it has been proven reliable and valid though with less items in prior research, as well as validated in the a labor migrants, most of whom are males with life experiences (Joseph, Joseph, Laura, Thomas, & Sara, 2006) With ten 4-point items the scale of depression experience has an α of 88 (Andresen, Carter, Malmgren, & Patrick, 1994; Cole, Rabin, Smith, & Kaufman, 2004; Kohout, Berkman, Evans, & Cornoni-Huntley, 1993; Santor & Coyne, 1997) The above five indicators serve as a latent construct of social structure (α = 60)

Information AIDS preventive information was assessed with ten true/false/don’t know items (Bryan, Fisher, & Benziger, 2001; Misovich, Fisher, & Fisher, 1997) Scoring the information scale was accomplished by dichotomizing each item into a value of (correct) and (incorrect or don’t know) and then summing the item values to form a composite score with higher scores on this scale reflecting increased knowledge about AIDS prevention (α = 60) The scale is split into two subscales One subscale includes items (α = 57) measuring theoretical knowledge or relevant to the sexual transmission of HIV (e.g., “Using condoms when you have sex can reduce the chance of getting HIV”); the sum of correct responses is the sexual transmission information score The other subscale comprises items (α = 62) that address HIV prevention heuristics (e.g., “Once you trust your partner you don’t need to use condoms with them”) The sum of correct responses is the heuristic information

score These two scores serve as indicators of the latent construct of AIDS prevention information Motivation was measured by twenty one 5-point items assessing respondents’ attitudes towards condom use [e.g., “How good or bad would it be if you talked about condom use (to keep from getting HIV/AIDS) with your sex partner(s) before having sex with them during the next month?”]; subjective norms or generalized perceptions of social support for their practice of condom use (e.g., “Most people who are important to you think you should talk about condom use with your partner(s) before having sex with them during the next month?”; and intentions to perform each condom behaviour (e.g., “If you have sex during the next month, you intend to talk about condom use with your partner(s) before having sex with them?”) (Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975; Misovich, Fisher, & Fisher, 1998) Respondents rate their performance of twenty one condom use statements on a 5-point semantic scale (bad-good) from (negative evaluation) to (positive evaluation) A composite score was obtained by summing responses to items with higher composite scores indicating higher levels of motivation toward condom use (α = 90)

Behavioural Skills Behavioural skills toward safer sex were assessed with seven items dealing with perceived self-efficacy to perform behaviors related to condom use The answers are on a 5-point semantic scale ranging from very hard (1) to very easy (5) (e.g., “How hard would it be for you to consistently use condoms with a partner every time you have sex with?”) (Bryan, et al., 2000; Misovich, et al., 1998) A composite score was obtained by summing responses to items with higher scores reflecting higher levels of behavioural skills for condom use (α = 86)

condom accessibility, and condom use (Misovich, et al., 1998), employed in a variety of safer versus riskier sexual practices Safer sex discussion was measured with two items that if the respondent has discussed safer sex (condom use) with sexual partner(s) and if he has tried to persuade a sexual partner to practice safer sex using a condom (α = 73), which were summed to create an indicator of safer sex discussion Condom accessibility was assessed with two items asking respondents how often they have purchased condoms and the extent to which they have kept easily available (α = 86), which were summed to create an indicator of condom accessibility Condom use during sexual intercourse was assessed with four items asking respondents about their frequency of condom use during intercourse (α = 83), which were summed to produce an indicator of condom use The above three subscales were summed to form a composite score of safer sex behaviour (α = 90)

Analysis Strategy The Pearson’s Product Moment correlation coefficient was used to determine whether pairs of factors are significantly associated with each other We used a conventional p value of 05 for these analyses Descriptive statistics (frequency, percentage, mean, SD, and range) were adopted to identify prevalence and levels of risky sexual behaviour

FINDINGS

Sample Characteristics Table displays socio-demographic data for the sample Nearly all men (98.7%) in the sample were ethnic Kinh, 84% were married, 73.8% followed one type of religion (Buddhism, catholic, and ancestor worship) Mobility was fairly high as most (63%) were born in rural areas Almost 70% resided in urban centres before traveling to Hanoi In the whole sample, 87% were migrants; the average number of cities for paid work was 2.4; and the average number of years in cities for paid works was 16.4 The mean age was 39 years and most had low levels of education (mean years completed=8.19) The majority (almost 60%) were farmers when in their hometowns and the most common occupation in urban areas were motorbike driver (~65%), followed by manual laborer and construction worker, each contributing more than 10% of the total The average monthly income was 2.6 million VND (equivalent to U.S.$140) Despite a fairly low level of alcohol consumption per drinking occasion, nearly all men consumed alcohol sometimes (over 90%) Level of access to HIV information was limited (M=3; range=0-9)

Table Selected Socio-Demographic Characteristics

Variable (N=450) n (%)

Mean ± SD

Age (year, range=18-59) 39.23±10.29

Marital status Unmarried Married

Separation/divorced/widowed/cohabitation

46(10.2) 378(84.0) 26(5.8) Race

Kinh Minors

444(98.7) 6(1.3) Religion

Buddhism

Catholic/Christian Ancestor worship None

116(25.8) 9(2.0) 207(46.0)

upload.123doc.ne t(26.2)

Education level (class completed, range=0-15) 8.19±2.52

Place of birth Urban Rural

167(37) 283(63) Place of residence before Hanoi

Urban Rural

314(69.8) 136(30.2)

Number of cities traveled for paid works 2.41±2.68

Mobility 392(87%) Living with whom in urban area

Alone

Peers and friends

Sex partners (wife, lovers, casual partners, sex workers & others) Family and relatives

46(10.2) 147(32.7) 202(44.9) 55(12.2) Main occupation during urban stay

Manual laborer

Construction worker and subcontractor Porter Motorbike driver Small trader Others 55(12.2) 49(13.1) 29(6.4) 291(64.7) 19(4.2) 7(1.6) Main occupation during hometown

Farmer

Construction worker

Office staff and factory worker Militant Motorbike driver Student Unemployed 263(58.5) 36(8.0) 40(8.9) 7(1.6) 55(12.2) 19(4.2) 30(6.6) Average income (million Vietnam dong, $USD1=VND18,000; range=.09-12) 2.60±1.30 Alcohol Use

Level of consumption (0-28.50) Percentage

5.66±4.83 416(92.22)

Social Connectedness (4-24) 16.81±3.79

Depression

Level of depression (0-27) Percentage

6.65±5.16 113(25.11)

Access to AIDS Information (0-9) 3.01±1.32

As can be seen in Table 2, there were deficits in HIV prevention behaviour More than 70% incorrectly believed that condoms only need to be used with prostitutes More than 50% incorrectly believed that once you trust your partner, you no longer need to use condoms with them, and many believed there is a cure for AIDS Around 60% incorrectly believed that oral sex is just as risky as vaginal intercourse for transmitting the virus, and as many men believed that you can tell by looking at someone if they have HIV, and there is currently a vaccine that prevents AIDS On a more positive note, over 98% knew that using condoms when you have sex can reduce the chance of getting HIV and more than 86% did not believe that it is safe to use the same condom more than once

Table Percentage and Level of Correct Responses to Knowledge of HIV/AIDS

Variable (N=450) n (%) # of Correct

Responses # of items n(%)

Using condoms when you have sex can reduce the chance of getting HIV (true)

443(98.4) 4(.9) It is safe to use the same condom more than once (false) 389(86.4) 23(5.1) Oral sex is just as risky as vaginal intercourse for transmitting HIV

(false)

190(42.2) 44(9.8) Condoms only need to be used with prostitutes (false) 127(28.2) 62(13.8) Once you trust your partner, you don’t need to use condoms with them

(false) 129(48.6) 101(22.4)

It is safe to have sex without a condom if it’s with your wife (false) 50(11.1) 85(18.9) As long as both partners wash themselves after sex, it is not necessary

to use condoms (false)

There is a cure for AIDS (false) 207(46.0) 10 7(1.6) Table displays general patterns of risk sexual behaviours for HIV Most participants (92.2%) reported that they were were heterosexual, 5.6% were bi-sexual, and 2.2% were homosexual The number of reported lifetime sexual partners ranged from to 77 with a mean of 10 (SD=7.5) Number of partners in the past year ranged from to 20 with a mean of 3.2 Around 95% of the participants had sexual encounters with regular partners, one third with sex workers, and almost 25% with casual partners Safer sex discussion with sex partners before having sex was fairly limited, with just over 50% of the participants saying that they talked about condom use Access to condoms was also relatively limited – those reporting buying condoms and keeping a condom available were in the minority Condom use among participants was inconsistent and with the proportions being just under one third with regular partners and commercial sex workers and very low (17.6%) with casual partners

Table Prevalence and Levels of Sexual Risk Behaviours for HIV

Variable n (%)

Mean ± SD

Sexual orientation (N=450) Sex only with men Sex only with women

Sex with both men and women

10(2.2) 415(92.2) 25(5.6)

Age at first sex (N=435) (range=15-52) 22.46±3.69

Types of sexual partners (N=450)

Regular partners (participants don’t pay for sex) Commercial sex workers (participants pay for sex) Casual sex partners (participants don’t pay for sex)

427(94.9) 147(32.7) 109(24.2) Multiple sex relations (N=450)

# of different partners (lifetime) (range=0-77) # of different partners (past year) (range=0-20)

10.1±7.54 3.17±2.10 Safer sex discussion with sex partners before having sex (past year) (N=435)

Talking about condom use with sex partners before having sex

Level of persuading condom use with sex partners before having sex (range=0-2)§

255(58.6) 78±.70 Condom accessibility (past year) (N=450)

Level of buying a condom (range=0-4)§

Level of keeping a condom available (range=0-4)§

1.55±1.10 1.81±1.29 Condom use

Last sex with regular partners (N=426) Last sex with commercial workers (N=149) Last sex with casual partners (N=110)

Level of past year condom use with regular partners (N=427) (range=0-4)§ Level of past year condom use with commercial workers (N=152) (range=0-4)§ Level of past year condom use with casual partners (N=112) (range=0-4)§ Level of past year condom use with all sex partners (N=435) (range=0-4)§

132(29.3) 137(30.4) 79(17.6) 1.26±1.17 3.32±1.10 2.47±1.42 1.83±1.04

Protected sex behaviour (range=0-26) (n=450) 14.70±6.24

§Range from to with higher scores indicating higher levels of the practice

The means, standard deviations and intercorrelations between key factors in the modified IMB model with an additional factor – social structure - are shown in Table HIV knowledge was limited (M=4.40; range=1-10), whilst motivation, perceived behavioural skills, and preventive behaviour were moderate With regard to intercorrelations among constructs, the majority of the scale scores were moderately to closely related to one another (r’s=.30-.60; p<.05)

Table Correlates of Key Factors with Protected Sex Behaviour

Variable (N=450) Mean ± SD

Social Structure (range=34.5-105.3)¥ 83.40±11.86 _

HIV Knowledge (range=1-10)¥ 4.40±1.83 21*** _

HIV Motivation (range=28-105)¥ 82.16±13.31 50*** .11* _

Safer Sex Behaviour (range=0-26)¥ 14.70±6.24 34*** .12* 24*** 16** _ ¥Ranges with higher scores indicate higher levels of the scale

DISCUSSION

Like many other developing countries, Vietnam is hosting an increasing number of migrants from rural to urban areas Other research in Asia and Africa has shown that people who migrate for work are at increased risk for HIV (Decosas & Adrien, 1997; M N Lurie, Williams, Zuma, Mwamburi, et al., 2003) They often have higher infection rates than those who not move (M N Lurie, Williams, Zuma, Mwamburi, et al., 2003) In this study, as most respondents (87%) were migrants, we examined the effect of mobility on sexual risk behaviour in relation to a wide spectrumof possible influences

The findings reveal a general pattern of sexual risk among the Vietnamese migrant labouring population, The perrcentage of migrants in the present study who reported having intercourse with commercial sex workers (32.7%) was similar to reports among the Chinese migrants (31%) (Li, Fang, Lin, Mao, Wang, Liu, et al., 2004), and was substantially higher than commencial sexual activity among indigenous rural Chinese (7.8%) in other studies (Liu et al., 1998) The number of lifetime and past year sexual partners, the percentage and level of condom use discussion and persuasion to take precautions with sexual partners also indicate high levels of risk sexual behaviour among migrant labourers These results are consistent with data from other countries in both Asia and Africa (M Lurie, Harrison, Wilkinson, & Aldool Karim, 1997; M N Lurie, Williams, Zuma, Mkaya-Mwamburi, et al., 2003)

The current study has shown that many factors, including those constructs adopted from the IMB model, are associated with risk sexual behaviours in this population In particular, sexual risk was associated with limited knowledge of HIV and low motivation and perceived low behavioural skills toward safer sexual behaviour When the bivariate correlation between these factors is assessed in isolation, the contributions of all of the IMB model constructs with behaviour were significant This finding is consistent with other studies conducted in developed and developing countries (Bryan et al., 2001; Cornman et al., 2007; Fisher, J., & Fisher, W A., 1998) This is one of the first studies in Vietnam demonstrating the applicability of these theoretical constructs in behavioural decision making related to sex However, it is important to consider the limitations of the standard IMB model Bryan, et al (2000) and Odutolu (2005) have argued that a main limitation of the IMB model was that its constructs were largely individual-level based, suggesting a need for building models that more explicitly take into account the larger social context In this study we introduced a broader range of social variables to examine how they are associated with each construct of the IMB model and with sexual behaviour The associations of social structure with all the IMB constructs and with the risk sexual behaviour were significant

It is recommended that future preventive interventions should address all aspects of migrants’ vulnerability to infection, not only their needs for information As argued by Li, Fang, Lin, Mao, Wang, Liu, et al (2004), an HIV prevention program is unlikely to be effective for people who are disconnected from formalized education, employment, and health care, and other social services

This study has some limitations The cross-sectional nature of the data may preclude any causality assessment Second, we are subject to the usual limitations of self-report bias in measures of sexual behaviour Also, our study has not simultaneously assessed the contributions of all of the IMB model constructs and social structure with behaviour using structural equation modeling – SEM, consequently the fit of the IMB model with an additional construct – social structure has yet to be analysed Further research, ideally with an intervention or a longitudinal design is needed to determine causal relationship among the model constructs as well as the effect of the intervention on male migrant freelance labourers’ behaviour To be effective, more prevention programs and a comprehensive public health approach to the specific needs and vulnerabilities of these men should be applied There is a great need to improve access to condoms for these men especially given the high numbers of casual and commercial partners, and also to have messages tailored for the substantial proportion of non-heterosexual men among these migrant labourers (about 8%) Understanding and application of this IMB theoretical model for best practice may facilitate more effective HIV/AIDS prevention intervention programs in Vietnam and countries that have similar contexts

This study was supported by a combined grant by the Institute of Health and Biomedical Innovation from the Queensland University of Technology, and the Australian Government's Overseas Aid Program (AusAID) Dr Jeffrey D Fisher, Professor of Psychology, Director, Center for Health, Intervention, and Prevention, University of Connecticut, USA, was greatly acknowledged for his provision of the related invaluable materials The authors also thank the field teams for their tireless efforts to assist this study The authors gratefully acknowledge the participation of all male migrants labourers in the survey interviews in Hanoi city, Vietnam

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IMPACT OF METHADONE ON THE MENTAL HEALTH, QUALITY OF LIFE AND SOCIAL INTEGRATION OF INJECTING DRUG USERS IN VIETNAM

Authors: Nguyen Thi Huynh1*; Nguyen Thanh Long1; Tran Vu Hoang2;

Rachel Burdon2; Nguyen To Nhu2; Tran Thi Thanh Ha2; Chi Nguyen2;

Kevin P Mulvey3; Nguyen Thi Minh Tam1; Nguyen Quynh Mai1; Le Truong Giang4;

Tieu Thi thu Van4; Vu Van Cong5; Pham Huy Minh6; Nguyen Thi Minh Ngoc6

(*) Presenting author

1 Vietnam Administration of HIV/AIDS Control, Ministry of Health 2 Family Health International, Vietnam

3 SAMHSA, PEPFAR Vietnam

4 Provincial AIDS for HIV/AODS Control Committee, Ho Chi Minh City 5 Provincial HIV/AICS Control Center, Hai Phong city

6 US Agency for International Development (USAID), Vietnam country office

I Background

The HIV/AIDS Estimates and Projection Report in Vietnam 2007- 2012 , reports that HIV prevalence is highest among high-risk populations including IDUs, female sex workers (FSWs), and men who have sex with men (MSM) According to Ministry of Public Security , up until the end of 2008, there were about 170,000 known IDU in Vietnam, 30 percent of whom were living with HIV or potentially infected with HIV

The pilot methadone program started in two provinces of Vietnam in 2008 This pilot in Hai Phong and Ho Chi Minh City (HCMC) has the following objectives; to reduce the transmission of HIV and related infections among opiate users people; 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.”

FHI Vietnam supported the VAAC to undertake a cohort study to examine the effectiveness and impact of the MMT pilot It was designed to measure and monitor changes in physical health status and mental health status, drug use, HIV risk behavior, criminal behavior and quality of life of patients

II Methodology

The study is a descriptive, prospective cohort study of clients treated at six methadone clinics in Hai Phong and HCMC Clinical outcome data (therapeutic doses and changes in dosing during treatment, clinical features, and withdrawal symptoms) were abstracted from client records Behavioral data was collected through personal interviews before treatment, at three months, at six months, and at nine months Client drug use was monitored through urine testing and the study team collected blood samples for HIV testing, Hepatitis B, and Hepatitis C before treatment and after six months The study team measured quality of life using tools developed by the WHO (WHOQOL-BREF) 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 966 individuals selected for the MMT program (prior to treatment) between January 2009 and October 2009 were eligible for this study except those who were not willing to participate and not in good health Data collection began in January 2009 and all results entered in Microsoft Access All personal interviews were made by trained research staff at sites that were confidential and private All data was encrypted by research code and no personal information appeared on any materials Analysis of the study’s variables, including the calculation of percentage (percent), average, and mean values, was based on the data sets for each round of investigation The study team compared client date from before treatment to data during treatment at three months, six months, and nine months and measured analyzed any changes based on the Friedman test for non-parametric data and correlated data

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

Baseline Results

The median age for the study population was 30 years (range, 16.6 to 58), the majority were male (95%) 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% stated that they shared a house with a drug user Most patients had a low educational level, with about 56% had only secondary education or lower and less than 5% finished some colleges or university 64% of the study population reported being employed Just over 27 percent were day laborers performing basic tasks and only 11.3 percent were steadily employed at the time of the study, usually for the family business

Approximately 98 percent of study participants in Hai Phong and 79 percent in HCMC had their own income The average monthly income was about VND 6.9 million ($365) Majority of patients received substantial amount of financial support from family (74.4%), with average of VND 5.11 million per month ($268) Nearly 41 percent of participants said that they had been involved in crime (apart from illegal drug use) to support their drug use

On average, participants had started using drugs by age 21 and 50 percent had started before 20 The most common primary drug at first use was heroin (88%), followed by opium (9%) About 98 percent participants surveyed in the two cities had tried to stop using drugs at least once and average number of attempts was six, before joining the methadone program At baseline, 12.1% of patients enrolled in the MMT program had chronic medical problems, and 40% of them were currently taking prescribed medication on a regular basis 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 (42.9% v.26.9%), higher Hepatitis B (20.6% v.11.5%) and more Hepatitis C (69.7% v 40.8%) The average Kessler score rating depression was 20 with 25% of IDU in HCMC having a Kessler score of 30 or over indicating severe depression/anxiety 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”, meaning the participant’s environment

Quality of life prior to treatment

Hai Phong (n= 467)

HCMC (n= 498)

Total (n= 965)

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)

Satisfaction with 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)

About 70% of all participants responded that their quality of life was average 10.9% rated their quality of life as “bad” and 1.5% as “very bad” Average score for participants’ physical health prior to treatment was 68, the highest in the four categories relating to quality of life Other average scores were 56.1 for mental health, 53.0 for society and 58.9 for environment

Results: Over Time

The number of patients using heroin (self report and urine test) dropped dramatically in the first three months and plateaued at 6-9 months are around 18%

Over time, quality of life improved considerably for new MMT patients Before MMT, only 16 percent of participants said they had “good” or “very good” quality of life but at nine months, 52% of patients reported this The proportion of patients who were “pleased with their health” also increased from 31 percent before treatment to around 60 percent during treatment Social and environmental domains of QoL also improved, but more slowly

Quality of life for MMT clients before treatment, at three months, at six months, and at nine months

Mental health improved significantly for MMT clients and the average Kessler score was seen to reduce markedly over time with a large increase in the proportion of clients whose average Kessler score was < 15 (no risk of depression) In addition suicidal ideation dropped from 15.3% at baseline to 0.5% at months Rates of anxiety also reduced dramatically

Average Kessler score for patients before MMT, at 3, and months

at months Rates of full time employment increased from 42 percent to 55 percent after nine months of treatment with most work reported 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

Employment Rates

Unemployed before treatment at three months, , six months, and nine months

Full-time employment with stable income before treatment, at three months, six months, and nine months

Self-reported crime reduced from 41% at baseline to 2.3% after months and 0.8% after months MMT also clearly helped participants reintegrate into society and into their families Family conflicts (and conflicts with neighbors and friends) also dropped considerably, from 20 percent prior to treatment to 3.56 percent after nine months

Incidence of crime over time

IV Discussion: MMT has been shown to have a major impact on improving physical and mental health and overall quality of life of IDU

1 Physical and mental health status of participants improved in general - only 10 percent patients reported being depressed at nine months of treatment, compared with almost 80 percent before treatment

2 Quality of life of patients improved remarkably – particularly physical and mental health Employment increased for participants the longer they stayed in treatment course, although many participants worked for family businesses or day labor

V Recommendations

1330 ite: www.leahrn.org http://www.ni.unimelb.edu.au/disease_prevention and health_promotion/hiv_aids/current_projects_and_consultancies/hiv_injecting_drug_use/lehrn 1523 Medline doi:10.1097/QAD.0b013e3282004929 462 Medline doi:10.1097/00002030-200202150-00018 doi:10.1007/s10461-007-9265-0 326 Medline doi:10.1097/00007435-200007000-00004 141 Medline doi:10.1136/sti.2006.023556 1466 Medline doi:10.1086/508548 88 Medline 167 Medline doi:10.1007/s10461-005-9061-7