Transcript Document

Community Attitudes Toward Harm Reduction
for Injection Drug Users (IDUs): Evidence
from a Cross-Border HIV Prevention Project
in Ning Ming County (Guangxi Province),
China and Lang Son Province, Vietnam
Theodore M. Hammett, Ph.D., Abt Associates Inc., Cambridge, MA, USA
Giulia D. Norton, M.P.H., Abt Associates Inc.
Ryan Kling, M.A., Abt Associates Inc.
Wei Liu, M.D., Guangxi Center for HIV/AIDS Prevention and Control,
Nanning, China
Yi Chen, M.D., Guangxi Center for HIV/AIDS Prevention and Control
Doan Ngu, M.D., Hanoi, Vietnam
Kieu Thanh Binh, M.D., Hanoi, Vietnam
Ha Viet Dong, M.D., Hanoi, Vietnam
Don C. Des Jarlais, Ph.D., Beth Israel Medical Center, New York City,
NY, USA
Abstract TuOrC1113
XV International AIDS Conference, Bangkok
July 13, 2004
Funding Support
• National Institute on Drug Abuse, Grant No. DA-14703 –
Research
• Ford Foundation (Beijing and Hanoi) – Interventions
Address for Correspondence:
Theodore M. Hammett, Ph.D.
Abt Associates Inc.
55 Wheeler Street
Cambridge, MA 02138 USA
[email protected]
Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project
XV International AIDS Conference, Bangkok — July 13, 2004
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Background
• First-ever cross-border HIV prevention project (with
interventions on both sides) targeting IDUs
• Drug Trans-shipment Routes  Heroin Use  Heroin
Injection  HIV Transmission  Increasing HIV
Prevalence  Cross-Border Transmission
• Other Cross-Border Movement
– Small-scale movement across long, porous
border
– Trade, migratory employment, “floating
population”
– Intermarriage, ethnic minority groups on both
sides
Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project
XV International AIDS Conference, Bangkok — July 13, 2004
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Geographic Setting
Map of Project
Sites
China
Ha Giang
Guigang
Area of Detail
Hanoi
Vietnam
China
Ning Ming City
Key:
Large Project Site
Small Border Site
Puzhai
Shilang
Aidian
Tan Thanh
Tongmian
Dong Dang
CaoLoc Town
Loc Binh
Hop
Thanh
Lang Son City
Vietnam
PDI Site
Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project
XV International AIDS Conference, Bangkok — July 13, 2004
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Intervention
• Peer-based education of IDUs (outreach model in
original sites)
• Peer-Driven Intervention (PDI) in two new sites: Ha
Giang, Vietnam, and Guigang, China
• Public health: collection/safe disposal of used
needles/syringes
• Social marketing of new needles/syringes — direct
distribution and through redemption of pharmacy
vouchers
• Community education
Full implementation of interventions in original sites
began July (Vietnam) – October (China), 2002
Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project
XV International AIDS Conference, Bangkok — July 13, 2004
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Evaluation
• Methods
– Pre- and multiple-post intervention follow-up
• Cross-sectional surveys of IDUs — baseline + 6, 12, 18, 24,
30 months; Baseline, 6- and 12-month completed in China
and Vietnam
• HIV testing (with counseling)
• “Capture-recapture” component  HIV incidence
estimation, longitudinal behavior change
– KAP surveys in community (HIV knowledge, knowledge
of/attitudes toward project) — same intervals as IDU surveys
– Process data
• Peer educator logs (contacts, collection of used
needles/syringes)
• Pharmacy/clinic logs (vouchers redeemed)
Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project
XV International AIDS Conference, Bangkok — July 13, 2004
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HIV Knowledge in the Community
“Correct” Answers
Knowledge of HIV
China
Baseline
(n = 321)
%
Vietnam
12 Months
(n = 307)
%
p-value
Baseline
(n = 250)
%
12 Months
(n = 250)
%
p-value
Transmitted
through needle
sharing
92.8
88.7
.07
99.6
97.9
.10
Not transmitted by
touching/hugging
an HIV+ person
75.1
86.4
.0002
89.8
87.2
.03
Not transmitted
through eating
with HIV+ person
55.5
70.8
<.0001
79.3
84.4
.23
Cannot tell HIV+
from appearance
55.1
73.4
<.0001
73.2
57.4
.0006
Can prevent HIV by
not sharing
needles
57.9
52.3
.14
62.5
69.9
.08
Can prevent HIV by
using condoms
58.9
70.5
.002
94.3
89.0
.07
Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project
XV International AIDS Conference, Bangkok — July 13, 2004
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Community Knowledge of HIV/AIDS
• Baseline levels of HIV knowledge were generally
higher in Vietnam and showed more improvement
in China.
• Continued community education is necessary to
overcome persistent misinformation and related
stigmatization.
Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project
XV International AIDS Conference, Bangkok — July 13, 2004
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Community Attitudes toward the Interventions
“Correct” Answers
Attitudes toward
Interventions
China
Baseline
(n = 321)
%
Vietnam
12 Months
(n = 307)
%
p-value
Baseline
(n = 250)
%
12 Months
(n = 250)
%
p-value
Will reduce
discarded
needles/syringes
57.3
57.5
.96
96.8
98.0
.61
Will reduce spread
of HIV
75.4
76.0
.85
96.8
98.7
.37
Will not increase
drug use
62.3
67.9
.13
71.4
68.7
.69
Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project
XV International AIDS Conference, Bangkok — July 13, 2004
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Community Attitudes toward the Interventions
• Baseline attitudes toward the interventions were more
positive in Vietnam but attitudes changed little at 12 months
• Community generally believes that the intervention will
reduce HIV spread (12-month results on HIV prevalence and
incidence)
• Community education is needed to dispel the common
misunderstanding that the intervention will lead to increased
drug use
• In fact, obtaining larger numbers of pharmacy vouchers
(Vietnam) or new needles/ syringes directly (China) from the
project was not associated with increased frequency of
heroin injection (Ning Ming: p = .38; Lang Son: p = .57)
Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project
XV International AIDS Conference, Bangkok — July 13, 2004
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HIV Prevalence in Each Site
Vietnam
Baseline
(n = 348)
6-Month
(n = 350)
12-Month
(n = 327)
Lang Son
57%
53%
49%
Cao Loc
42%
53%
43%
Loc Binh
41%
34%
34%
Dong Dang
40%
42%
35%
Tan Thanh
5%
14%
27%
All Lang Son Sites
46%
46%
43%
Baseline
(n = 308)
6-Month
(n = 343)
12-Month
(n = 307)
China
Aidian
32%
38%
19%
Tongmian
63%
44%
55%
Shilang
25%
29%
23%
Ning Ming City
12%
18%
9%
All Ning Ming Sites
17%
23%
14%
Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project
XV International AIDS Conference, Bangkok — July 13, 2004
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Estimated HIV Incidence Among IDUs
• Based on matched ID numbers in cross-sectional IDU surveys
• Limitations
– Numbers are very small (n = 38 susceptibles in Lang Son and n = 72
in Ning Ming, China
– Potentially missed matches due to some participants giving false
information for ID numbers (e.g., Ning Ming at 12 months — 36%
said they had participated in a previous survey, but only 21% of
records could be matched by ID numbers).
• Estimated annual incidence among IDUs
– Lang Son (12 months, 3 seroconversions, 2 in first 6 months, 1
between baseline and 12 months): 12.8% (95% CI: 2.5 – 64.2 )
– Ning Ming (12 months, 2 seroconversions, both between baseline
and 12 months): 4.5% (95% CI: 1.0 – 20.9)
– Note: Very wide confidence intervals
• Stable prevalence is likely to be maintained with 4 –8 % annual
incidence, because of attrition (e.g., deaths due to HIV/AIDS or
drug overdose)
Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project
XV International AIDS Conference, Bangkok — July 13, 2004
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Comments Regarding HIV Incidence
• HIV transmission has not been halted, but . . .
• HIV incidence appears to be going down: Lang Son
— baseline 18%, 12 months 13%; Ning Ming —
baseline 7%, 12 months 5% (Note: Different method
used for baseline calculation: HIV-positives who
reported injecting  5 years were assumed to have
been infected midway through self-reported injecting
history)
• Data from subsequent followup surveys should
improve the precision of the incidence estimates
Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project
XV International AIDS Conference, Bangkok — July 13, 2004
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Conclusions
• This is a path-breaking project, offering very important opportunities to
control a cross-border HIV epidemic and increase cross-border
collaboration.
• The interventions are generally acceptable to pharmacies, IDUs, police,
and the general community.
• Continued and increased attention is needed to stigmatization of drug
use and IDUs.
• Ongoing community education and regular meetings with all
stakeholders are essential to maintain support and understanding.
• HIV Prevalence is stable through 12-month followup.
• HIV transmission has not been halted but incidence but may be coming
down.
• Further evidence of the effectiveness of the interventions awaits
subsequent followup IDU and community surveys.
Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project
XV International AIDS Conference, Bangkok — July 13, 2004
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Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project
XV International AIDS Conference, Bangkok — July 13, 2004
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