Working With Persons Who Inject Drugs and Live in Rural Areas: Implications From China/Vietnam for the USA.

PURPOSE OF REVIEW: To describe a small city/rural area HIV prevention project (the Cross Border Project) implemented in Ning Ming County, Guangxi Province, China, and Lang Son province, Vietnam, and consider its implications for addressing the opioid/heroin epidemic in small cities/rural areas in the USA. The description and the outcomes of the Cross Border project were taken from published reports, project records, and recent data provided by local public health authorities. Evaluation included serial cross-sectional surveys of people who inject drugs to assess trends in risk behaviors and HIV prevalence. HIV incidence was estimated from prevalence among new injectors and through BED testing. RECENT FINDINGS: The Cross Border project operated from 2002 to 2010. Key components of the project 2 included the use of peer outreach workers for HIV/AIDS education, distribution of sterile injection equipment and condoms, and collection of used injection equipment. The project had the strong support of local authorities, including law enforcement, and the general community. Significant reductions in risk behavior, HIV prevalence, and estimated HIV incidence were observed. Community support for the project was maintained. Activities have been continued and expanded since the project formally ended. The Cross Border project faced challenges similar to those occurring in the current opioid crisis in US small cities/rural areas: poor transportation, limited resources (particularly trained staff), poverty, and potential community opposition to helping people who use drugs. It should be possible to adapt the strategies used in the Cross Border project to small cities/rural areas in the US opioid epidemic.

Prevalence and correlates of HIV infection among men who inject drugs in a remote area of Vietnam.

BACKGROUND: Lack of information on the HIV epidemic among men who inject drugs (MWID) in northwestern Vietnam, a remote area, may hamper national efforts to control the disease. We examined HIV prevalence, needle-syringe sharing behaviors, and associated factors among MWID in three areas of northwestern Vietnam. METHODS: We used descriptive analysis to report the characteristics, frequency of risk behaviors, and of access to healthcare services among the MWID. Univariable logistic regression was used to assess the associations between the HIV infection, needle-syringe sharing behaviors, and their independent variables. We further explored these associations in multivariable analyses where we included independent variables based on a priori knowledge and their associations with the dependent variables determined in univariable analyses (p <  0.25). RESULTS: The HIV prevalence was 37.9, 16.9, and 18.5% for Tuan Giao, Bat Xat, and Lao Cai City, respectively, and 25.4% overall. MWID of Thai minority ethnicity were more likely to be HIV-positive (adjusted odds ratio (AOR) 3.55; 95% confidence interval (CI) 1.84-6.87). The rate of needle-syringe sharing in the previous 6 months was approximately 9% among the MWID in Tuan Giao and Lao Cai City, and 27.8% in Bat Xat. Two thirds of the participants never underwent HIV testing before this study. Ever having been tested for HIV before this study was not associated with any needle-syringe sharing behaviors. Among the HIV-positive MWID, those who received free clean needles and syringes were less likely to give used needles and syringes to peers (AOR 0.21; 95% CI 0.06-0.79). Going to a "hotspot" in the previous week was associated with increased odds of needle-syringe sharing in multiple subgroups. CONCLUSION: Our findings on HIV prevalence and testing participation among a subset of MWID in the northwestern Vietnam were corroborated with trend analysis results from the most recent HIV/STI Integrated Biological and Behavioral Surveillance report (data last collected in 2013.) We provided important insights into these MWID's risky injection behaviors. We suggest heightened emphasis on HIV testing and needle and syringe provision for this population. Also, policymakers and program implementers should target hotspots as a main venue to tackle HIV epidemics.

Female sexual partners of male people who inject drugs in vietnam have poor knowledge of their male partners' HIV status.

BACKGROUND: Vietnam's HIV epidemic is concentrated among male people who inject drugs (PWID), and their female sexual partners (SPs) may be at risk for infection. HIV prevention interventions for SPs were implemented in Hanoi, Dien Bien Province, and Ho Chi Minh City (HCMC), and data from linked surveys used to evaluate these interventions offered an unusual opportunity to assess knowledge of HIV status within couples. METHODS: Linked surveys (behavioral interviews and HIV testing) among 200 PWID-SP couples in Hanoi, 300 in Dien Bien, and 249 in HCMC. RESULTS: HIV prevalence among male PWID was 53% in Hanoi, 30% in Dien Bien, and 46% in HCMC, and lower among their SPs: 44%, 10%, and 37%, respectively. Comparison of SPs' beliefs regarding male PWID partners' HIV status with the PWIDs' actual test results revealed that 32% of SPs in Dien Bien and 44% in Hanoi and HCMC lacked correct knowledge of their male partners' status. This proportion was slightly lower (21%-33%) among SPs whose PWID partners reported having been previously tested and received HIV+ results. CONCLUSIONS: SP interventions reached HIV-negative women in serodiscordant relationships, and some improvements occurred in condom use and relationship characteristics. Nevertheless, our findings suggest that at least 11,000 SPs in Vietnam may be at high risk for HIV infection because of incorrect knowledge of their partners' HIV status. Interventions should be strengthened in HIV testing, disclosure, and treatment, as well as empowerment of SPs as individuals, within couples, and as communities.

Controlling HIV epidemics among injection drug users: eight years of Cross-Border HIV prevention interventions in Vietnam and China.

INTRODUCTION: HIV in Vietnam and Southern China is driven by injection drug use. We have implemented HIV prevention interventions for IDUs since 2002-2003 in Lang Son and Ha Giang Provinces, Vietnam and Ning Ming County (Guangxi), China. METHODS: Interventions provide peer education and needle/syringe distribution. Evaluation employed serial cross-sectional surveys of IDUs 26 waves from 2002 to 2011, including interviews and HIV testing. Outcomes were HIV risk behaviors, HIV prevalence and incidence. HIV incidence estimation used two methods: 1) among new injectors from prevalence data; and 2) a capture enzyme immunoassay (BED testing) on all HIV+ samples. RESULTS: We found significant declines in drug-related risk behaviors and sharp reductions in HIV prevalence among IDUs (Lang Son from 46% to 23% [p<0.001], Ning Ming: from 17% to 11% [p = 0.003], and Ha Giang: from 51% to 18% [p<0.001]), reductions not experienced in other provinces without such interventions. There were significant declines in HIV incidence to low levels among new injectors through 36-48 months, then some rebound, particularly in Ning Ming, but BED-based estimates revealed significant reductions in incidence through 96 months. DISCUSSION: This is one of the longest studies of HIV prevention among IDUs in Asia. The rebound in incidence among new injectors may reflect sexual transmission. BED-based estimates may overstate incidence (because of false-recent results in patients with long-term infection or on ARV treatment) but adjustment for false-recent results and survey responses on duration of infection generally confirm BED-based incidence trends. Combined trends from the two estimation methods show sharp declines in incidence to low levels. The significant downward trends in all primary outcome measures indicate that the Cross-Border interventions played an important role in bringing HIV epidemics among IDUs under control. The Cross-Border project offers a model of HIV prevention for IDUs that should be considered for large-scale replication.