The feasibility of a syringe-needle-exchange program in Vietnam

Gender Differences in HIV, HCV risk and Prevention Needs Among People who Inject drug in Vietnam

We examined gender differences among people who inject drug (PWID) in Hai Phong, Vietnam in term of blood-borne infections, risk behaviors, and access to care. Using respondent-driven-sampling surveys, we recruited 3146 PWID from 2016 to 2018. Inclusion criteria included a positive urine test for heroin and recent injection marks. There were 155 female PWID (4,9%), including 82 at RDS-2016, 32 at RDS-2017 and 38 at RDS-2018. The age mean was 36.3 ± 7.2 years. The majority of female PWID had less than high school education (90.9%) and were unemployed (51.3%). There was no difference in the proportion of HIV and HCV positive by gender. However, women had several significant differences in risk behaviors than men in multivariable logistic regression. Being a woman was independently associated with being unemployed, being a sex worker, having unstable housing, having uses drugs for less than 5 years, more use of methamphetamine, having a partner who ever injected drugs, and less access to methadone treatment. Interventions targeting female PWID are needed, possibly through community organizations and peer educators.

Estimating the Cost-Effectiveness of HIV Prevention Programmes in Vietnam, 2006-2010: A Modelling Study

Introduction

Vietnam has been largely reliant on international support in its HIV response. Over 2006-2010, a total of US$480 million was invested in its HIV programmes, more than 70% of which came from international sources. This study investigates the potential epidemiological impacts of these programmes and their cost-effectiveness.

Methods

We conducted a data synthesis of HIV programming, spending, epidemiological, and clinical outcomes. Counterfactual scenarios were defined based on assumed programme coverage and behaviours had the programmes not been implemented. An epidemiological model, calibrated to reflect the actual epidemiological trends, was used to estimate plausible ranges of programme impacts. The model was then used to estimate the costs per averted infection, death, and disability adjusted life-year (DALY).

Results

Based on observed prevalence reductions amongst most population groups, and plausible counterfactuals, modelling suggested that antiretroviral therapy (ART) and prevention programmes over 2006-2010 have averted an estimated 50,600 [95% uncertainty bound: 36,300–68,900] new infections and 42,600 [36,100–54,100] deaths, resulting in 401,600 [312,200–496,300] fewer DALYs across all population groups. HIV programmes in Vietnam have cost an estimated US$1,972 [1,447–2,747], US$2,344 [1,843–2,765], and US$248 [201–319] for each averted infection, death, and DALY, respectively.

Conclusions

Our evaluation suggests that HIV programmes in Vietnam have most likely had benefits that are cost-effective. ART and direct HIV prevention were the most cost-effective interventions in reducing HIV disease burden.

Negotiating access: social barriers to purchasing syringes at pharmacies in Tijuana, Mexico

BACKGROUND

One common public health response to the emergence of HIV has been the provision of sterile syringes to people who inject drugs. In Mexico specialized syringe exchanges are rare, and the sale of needles through pharmacies is often the only way people who inject drugs can obtain sterile syringes. However, people who inject drugs in Tijuana, Mexico report considerable social barriers to successfully purchasing syringes at pharmacies.

METHODS

Between October 2008 and March 2009 we conducted seven in-depth focus groups with 47 people who inject drugs in Tijuana, Mexico. Focus group transcripts were analysed using a descriptive and thematic approach rooted in grounded theory.

RESULTS

We found that injectors offered a number of explanations for why pharmacies were reluctant to sell them syringes, including fear of police; attitudes toward drug use; fear of stereotypical drug user behaviour such as petty theft, violence, or distressing behaviour; and related fears that an obvious drug using clientèle would drive away other customers. Injectors described a range of ways of attempting to re-frame or negotiate interactions with pharmacy staff so that these and related concerns were ameliorated. These included tactics as simple as borrowing cleaner clothing, through to strategies for becoming 'known' to pharmacy staff as an individual rather than as a member of a stigmatized group.

CONCLUSION

Increasing the ability of pharmacy staff and people who inject drugs to successfully negotiate syringe sales are highly desirable. Interventions designed to improve this likelihood need to capitalize on existing solutions developed ad hoc by people who inject drugs and pharmacy staff, and should focus on broadening the range of 'identities' which pharmacy staff are able to accept as legitimate customers. Approaches to achieve this end might include sensitizing pharmacy staff to the needs of people who inject drugs; facilitating individual drug users meeting individual pharmacy staff; and working with drug users to reduce behaviours seen as problematic by pharmacy staff.

Liver disease in Viet Nam: screening, surveillance, management and education: a 5-year plan and call to action

Despite a high prevalence of liver disease in Viet Nam, there has been no nationwide approach to the disease and no systematic screening of at-risk individuals. Risk factors include chronic hepatitis B (estimated prevalence of 12%), chronic hepatitis C (at least 2% prevalence), and heavy consumption of alcohol among men. This combination of factors has resulted in liver cancer being the most common cause of cancer death in Viet Nam. There is a general lack of understanding by both the general public and health-care providers about the major risk to health that liver disease represents. We report here the initial steps taken as part of a comprehensive approach to liver disease that will ultimately include nationwide education for health-care providers, health educators, and the public; expansion of nationwide screening for hepatitis B and C followed by hepatitis B virus vaccination or treatment of chronic hepatitis B and/or hepatitis C; education about alcoholic liver disease; long-term surveillance for liver cancer; reduction of infection transmission related to medical, commercial, and personal re-use of contaminated needles, syringes, sharp instruments, razors, and inadequately sterilized medical equipment; and ongoing collection and analysis of data about the prevalence of all forms of liver disease and the results of the expanded screening, vaccination, and treatment programs. We report the beginning results of our pilot hepatitis B screening program. We believe that this comprehensive nationwide approach could substantially reduce the morbidity and mortality from liver disease and greatly lessen the burden in terms of both lives lost and health-care costs.

Drug policy in Vietnam: a decade of change?

BACKGROUND

Driven by the rapid spread of HIV, Vietnam's response to drug use has undergone significant transformation in the past decade. This paper seeks to identify and analyse factors that prompted these changes and to investigate their impact on the lives of people who use drugs.

METHOD

This policy analysis is based on a review of Vietnamese Government documents, peer-reviewed publications and the authors' knowledge of and involvement in drug policy in Vietnam.

RESULTS

The last decade has witnessed a progressive change in the mindset of political leaders in Vietnam around illicit drug use and HIV issues. This has led to adoption of evidence-based interventions and the evolution of drug policy that support the scale up of these interventions. However, HIV prevalence among drug users at 31.5% remains high due to limited access to effective interventions and impediments caused by the compulsory treatment centre system.

CONCLUSIONS

The twin epidemics of HIV and illicit drug use have commanded high-level political attention in Vietnam. Significant policy changes have allowed the implementation of HIV prevention and drug dependence treatment services. Nevertheless, inconsistencies between policies and a continued commitment to compulsory treatment centres remain as major impediments to the provision of effective services to drug users. It is critical that Vietnamese government agencies recognise the social and health consequences of policy conflicts and acknowledge the relative ineffectiveness of centre-based compulsory treatment. In order to facilitate practical changes, the roles of the three ministries directly charged with HIV and illicit drug use need to be harmonised to ensure common goals. The participation of civil society in the policymaking process should also be encouraged. Finally, stronger links between local evidence, policy and practice would increase the impact on HIV prevention and drug addiction treatment programming.

Characteristics of high-risk HIV-positive IDUs in Vietnam: implications for future interventions

The HIV epidemic in Vietnam is concentrated primarily among injecting drug users (IDUs). To prevent HIV-1 superinfection and to develop effective HIV prevention programs, data are needed to understand the characteristics of high-risk HIV-positive IDUs. In 2003 , we conducted a community-based cross-sectional study among predominately male, out-of-treatment IDUs, aged 18?45, in the Bac Ninh Province, Vietnam. Among 299 male participants, 42.8% were HIV-positive, and among those, 96.9% did not know their status prior to the study. Furthermore, 32% were HIV-positive and had high HIV behavioral risk (having unprotected sex or having shared injecting equipment in the past 6 months). Injecting for ?3 years, younger age, and pooling money to buy drugs were independently associated with being at high risk for transmitting HIV. IDUs who purchased more than one syringe at a time were less likely to have high HIV behavioral risk. Structural interventions that increase syringe accessibility may be effective in reducing HIV risk behavior among HIV-positive IDUs. Study limitations are noted in the article.

Needle and syringe sharing practices among injecting drug users in Tehran: a comparison of two neighborhoods, one with and one without a needle and syringe program

This study was conducted to compare needle and syringe sharing practices among injecting drug users (IDUs) in two neighborhoods, one with and one without a needle and syringe program (NSP). In 2005, 419 street-based IDUs were interviewed at specific locations in two neighborhoods where IDUs are known to congregate. We compared self-reported needle and syringe access and use between IDUs from a neighborhood with an active NSP to IDUs from a neighborhood without such an intervention. A significantly smaller proportion of IDUs from the former neighborhood reported having used a shared needle/syringe over a 1-month period (21.0%) compared to IDUs from the latter neighborhood (39.9%; adjusted odds ratio, 0.24; 95% confidence interval, 0.13-0.45). These findings indicate that access to an NSP may reduce needle and syringe sharing practices. Therefore, these programs should be intensified in settings with concentrated HIV epidemics among IDUs in Iran.

Risks for HIV, HBV, and HCV infections among male injection drug users in northern Vietnam: a case-control study

Injection drug use (IDU) and HIV infection are important public health problems in Vietnam. The IDU population increased 70% from 2000 to 2004 and is disproportionately affected by HIV and AIDS -- the country's second leading cause of death. Hepatitis B virus (HBV) and hepatitis C virus (HCV) share transmission routes with HIV and cause serious medical consequences. This study aimed to determine risk factors for acquisition of HIV, HBV, and HCV infections among IDUs in a northern province. We conducted a matched case-control study among active IDUs aged 18-45 who participated in a community-based survey (30-minute interview and serologic testing). Each HIV-infected IDU (case) was matched with one HIV-uninfected IDU (control) by age, sex (males only), and study site (128 pairs). Similar procedures were used for HBV infection (50 pairs) and HCV infection (65 pairs). Conditional logistic regression models were fit to identify risk factors for each infection. Among 309 surveyed IDUs, the HIV, HBV, and HCV prevalence was 42.4%, 80.9%, and 74.1%, respectively. Only 11.0% reported having been vaccinated against hepatitis B. While 13.3% of the IDUs reported sharing needles (past six months), 63.8% engaged in indirect sharing practices (past six months), including sharing drug solutions, containers, rinse water, and frontloading drugs. In multivariable models, sharing drugs through frontloading was significantly associated with HIV infection (odds ratio [OR]=2.8), HBV infection (OR=3.8), and HCV infection (OR=4.6). We report an unrecognized association between sharing drugs through frontloading and higher rates of HIV, HBV and HCV infections among male IDUs in Vietnam. This finding may have important implications for bloodborne viral prevention for IDUs in Vietnam.

The development of peer educator-based harm reduction programmes in Northern Vietnam

INTRODUCTION

Injecting drug use remains an important risk factor for transmission in Vietnam, with an estimated 50% of the 290 000 people living with HIV/AIDS reporting injecting drug use as a risk factor. Despite this, effective harm reduction interventions are generally lacking. This paper describes the implementation of peer-based harm reduction programmes in two rural provinces of Vietnam.

DESIGN AND METHODS

Peer educators were trained in basic HIV prevention, including harm reduction. After significant preparation work with the Provincial AIDS Committees of Bac Giang and Thanh Hoa and other relevant national, provincial and local authorities, the interventions were commenced. Harm reduction interventions were delivered through outreach as well as on-site. This included needle and syringe distribution and collection.

RESULTS

Community advocacy occurred throughout the life of the project. Local authorities and peers believed that while there was a general reduction in stigma and discrimination, legal barriers associated particularly with the carrying of injecting equipment remained. This impacted upon the ability of peer educators to work with their clients.

CONCLUSION

Peer-based delivery of harm reduction intervention is acceptable. Harm reduction interventions, including needle and syringe programmes, are feasible and acceptable in these two rural Vietnamese provinces. Community acceptance and uptake of these interventions is key to successful expansion across the region. Active participation by families of drug users seems crucial. This initiative demonstrates that despite a difficult policy environment, peer-delivered needle and syringe programmes are feasible within a rural Asian environment as long as there is adequate local political and community support.

High HIV sexual risk behaviors and sexually transmitted disease prevalence among injection drug users in Northern Vietnam: implications for a generalized HIV epidemic

BACKGROUND

HIV prevalence in Vietnam is currently concentrated among injection drug users (IDUs). The extent to which this core risk group represents a potential for broader HIV transmission to the general population is currently unknown.

METHODS

A community-based cross-sectional study among IDUs in Vietnam assessed sexually transmitted disease (STD) prevalence and behavioral risk factors. Qualitative interview data enhanced quantitative findings.

RESULTS

The prevalence of any STDs among 272 IDUs was 30% (chlamydia, 9%; herpes simplex virus type 2 [HSV-2], 22%; gonorrhea, 0%; and syphilis, 1%). Part-time work or unemployment (odds ratio [OR] = 2.74, 95% confidence interval [CI]: 1.1 to 6.9), sex with > or =2 sex workers in the past year (OR = 4.9, 95% CI: 1.91 to 12.6), having ever smoked heroin (OR = 4.5, 95% CI: 1.1 to 18.3), and injecting less frequently than daily (OR = 3.9, 95% CI: 1.43 to 10.6) were independently associated with chlamydial infection. Urban residency (OR = 4.0, 95% CI: 1.4 to 11.0) and daily injecting (OR = 2.2, 95% CI: 1.1 to 4.4) were independently associated with HSV-2. Odds of HSV-2 among older (> or =28 years of age) IDUs who had sex with <2 sex workers in the past year was higher than among younger IDUs who had sex with more sex workers (OR = 6.4, 95% CI: 2.1 to 18.4).

CONCLUSIONS

High STD prevalence and high-risk sexual and parenteral behaviors among IDUs indicate the potential for HIV/STD transmission to the general Vietnamese population.

A situational analysis of HIV/AIDS-related discrimination in Hanoi, Vietnam

The laws in Vietnam provide a framework within which one may judge the nature and type of health care-related discrimination to which people living with HIV (PLWHA) are subject. Despite the existence of stringent legislation protecting the rights of PLWHA, this study found that, in practice, PLWHA experienced significant structural discrimination in their daily lives. The discrimination experienced by PLWHA was exacerbated by the fact that, historically, HIV is associated with high-risk, marginalized groups such as drug users and sex workers. In the health care sector, discriminatory practices (for instance, refusal to treat), differential treatment and non-confidentiality were frequent. For the development of successful prevention and treatment strategies, a mutually desirable and equitable balance must be achieved between individual rights and needs and individual obligations to the broader society.

Do needle syringe programs reduce HIV infection among injecting drug users: a comprehensive review of the international evidence

This first international review of the evidence that needle syringe programs reduce HIV infection among injecting drug users found that conservative interpretation of the published data fulfills six of the nine Bradford Hill criteria (strength of association, replication of findings, temporal sequence, biological plausibility, coherence of evidence, and reasoning by analogy) and all six additional criteria (cost-effectiveness, absence of negative consequences, feasibility of implementation, expansion and coverage, unanticipated benefits, and application to special populations). The Bradford Hill criteria are often used to evaluate public health interventions. The principal finding of this review was that there is compelling evidence of effectiveness, safety, and cost-effectiveness, consistent with seven previous reviews conducted by or on behalf of U.S. government agencies. Authorities in countries affected or threatened by HIV infection among injecting drug users should carefully consider this convincing evidence now available for needle syringe programs with a view to establishing or expanding needle syringe programs to scale.

Drug use among female sex workers in Hanoi, Vietnam

AIMS

To describe the drug use practices among female sex workers (FSWs) in Hanoi and to identify factors associated with their drug injecting.

DESIGN, SETTING AND PARTICIPANTS

A two-stage cluster survey of 400 FSWs was conducted from June to September, 2002. Participating FSWs were both establishment- (160) and street-based (240), who were practising in seven urban and one suburban districts of Hanoi.

MEASUREMENTS

Subjects were interviewed face to face using a structured questionnaire.

FINDINGS

Among the middle-class FSWs, 27% used drugs, of whom 79% injected. Among low-class FSWs, 46% used drugs and 85% injected. Among drug-using FSWs, 86% had started using drugs within the past 6 years. Among drug-injecting FSWs, 81% had started injecting within the past 4 years. Cleaning of injecting equipment was not common among those who shared. Having drug-injecting 'love mates', drug-using clients, longer residence in Hanoi, more clients and not currently cohabiting were found to be independently associated with drug injecting among FSWs.

CONCLUSIONS

The high prevalence of injecting drug use among FSWs makes them susceptible to HIV infection, and is a threat to their clients. There is a strong relationship between drug-using FSWs and male drug-using clients and non-client partners. Intervention to prevent drug use initiation among non-drug-using FSWs and harm reduction among drug-using FSWs are urgently needed.

Return Rates for Needle Exchange Programs: A Common Criticism Answered

This study searched the available needle exchange program (NEP) literature for return rate data. A total of 26 articles were found. The overall worldwide return rate was 90%, although this ranged from a low of 15% to a high of 112%. U.S. NEP return rates were gathered from only eight studies, indicating a clear need for more data, although U.S. return rates were comparable to those from NEPs outside of the U.S.

One underlying assumption made by opponents of NEPs is that IDUs will not return needles to the distribution site, thereby potentially increasing the risk of health problems to the surrounding community from exposure to contaminated needles. This study's results suggest that NEPs are relatively successful in taking in used needles, although it is generally unclear where the needles were originally acquired, and if IDUs return their own needles, or are returning needles for a social network. Ways for AIDS Service Organizations to capitalize on these brief encounters with IDUs, as well as public policy implications of the findings, are discussed.

HIV in Vietnam: the evolving epidemic and the prevention response, 1996 through 1999

OBJECTIVES

To describe epidemiologic patterns and trends in HIV infection in Vietnam from 1996 through 1999, and to summarize the national response to the epidemic.

METHODS

We reviewed nationwide HIV case reports, and we analyzed annual seroprevalence among different sentinel populations in 21 provinces, using the chi2 test for linear trend to assess trends in HIV prevalence. HIV prevention efforts were also reviewed.

RESULTS

Through 1999, 17,046 HIV infections, including 2947 AIDS cases and 1523 deaths had been reported in Vietnam. The cumulative incidence rate for the country was 22.5 per 100,000 population. Injection drug users (IDUs) represented 89.0% of all those for whom risk was reported before 1997 and 88.0% in the period 1997 to 1999. In 1999, HIV prevalence rates among IDUs ranged by province from 0% to 89.4%. Significantly increasing HIV trends among IDUs (p <.05) were found in 14 of the 21 sentinel provinces during 1996 to 1999. HIV prevalence among commercial sex workers (CSWs) ranged from 0% to 13.2%, increased significantly in 6 of 21 provinces. In 1999, prevalence among pregnant women, blood donors, and military recruits were 0.12%, 0. 20% and 0.61%, respectively. Major prevention activities include mass information; peer education and outreach among groups at increased risk; availability of low-cost syringes and condoms through pharmacies; needle exchange pilot projects; widely available treatment for sexually transmitted diseases; antibody screening of blood for transfusion; and free medical treatment at government hospitals.

DISCUSSION

The HIV epidemic continues to evolve rapidly, intensifying among IDUs and increasing among CSWs. Serosurveillance indicators of HIV in the population at large continue to indicate the relatively slow extension beyond those at highest risk. Immediate, intensive preventions in high-risk groups may decelerate expansion to the broader population.

Syringe availability as HIV prevention: a review of modalities

This review examines recent research into modalities for improving access to sterile syringes for injection drug users (IDUs) as a means to reduce human immunodeficiency virus (HIV) transmission. English language studies with empirical data were collected through Uncover reports and MedLine searches from 1998 to 2000. Although syringe-exchange programs are the most established and well-evaluated means of improving access to sterile syringes, research on alternative modalities-such as pharmacy sale, injector-specific packs, mass distribution, and vending machines-and on coverage of special populations suggests the need to pursue multiple avenues of increasing syringe availability simultaneously and, in particular, to explore modalities other than syringe-exchange programs when HIV incidence is under control. The impacts on HIV transmission of cocaine injection and sex with IDUs need to be explored further. Finally, any evidence of declining hepatitis C incidence among young IDUs might serve as a surrogate for a sharp drop in injection-related HIV risk behaviors in that population.