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.

A method for analyzing changing prison populations: explaining the growth of the elderly in prison.

BACKGROUND: For the past several decades, the U.S. prison system has witnessed a steady and persistent increase in the ages of prison populations. Given the additional costs and burdens placed on prisons as they house older inmates, this aging trend has generated intense interest among policy makers and academics who seek to understand why prison populations are getting older. OBJECTIVE: This article presents a method for evaluating drivers influencing the change in age distributions among prisoners. METHOD: We define a methodological approach and demonstrate its application using prison data from four states reporting to the Bureau of Justice Statistics' National Corrections Reporting Program. RESULTS: We find that since 2000, the primary driver of overall growth in the elderly populations in prison (defined as inmates over 50) is the increasing admission age of offenders entering prison. Moreover, changes in offense mix and sentence length/time served over the last decade have had significantly less influence on the age composition of prison populations. We also find that the impact of explanatory factors varies across states and offense types. For example, prison admission and exit rates explain much of the change in elderly drug offenders in New York, but not elderly violent offenders, where admission age plays a much stronger explanatory role. CONCLUSION: Our analysis offers an effective demonstration that supports the use of this method as an important and informative first step toward understanding components of change that affect the problem of prison aging.

Recent trends in substance abuse among persons with disabilities compared to that of persons without disabilities.

BACKGROUND: Substance abuse (SA) is a grave and pervasive social problem associated with severe personal and social costs that affect persons with disabilities disproportionally. Most previous research has found SA prevalence to be greater among persons with disabilities than among those without disabilities. OBJECTIVES: To compare prevalence between persons with disabilities and persons without disabilities for different substances of abuse, and recent SA trends. METHODS: The authors examined nine years of nationally representative data estimates from the National Survey on Drug Use and Health, comparing previous month prevalence of self-reported SA on a per-substance basis among community residing persons with disabilities and their peers without disabilities, using a logistic regression model that accounted for demographic factors. RESULTS: Prevalence of overall substance abuse (a composite measure) was level over time, at 34% for persons without disabilities and 40% for persons with disabilities. The SA prevalence among persons with disabilities closely paralleled that of other persons over the period 2002-2010 for each substance examined, but at a statistically significant higher level, with the exception of alcohol abuse, which was significantly lower. Time trends were relatively stable for both populations, with the exception of decreases in cocaine use and recent dramatic increases in marijuana use and oxycodone abuse. CONCLUSIONS: Given that substance abuse among persons with disabilities is markedly more prevalent than among other persons for most substances, findings indicate a need for accessible, targeted prevention programs and a potentially overwhelming demand for accessible SA treatment services and facilities.

Linkage to HIV care for jail detainees: findings from detention to the first 30 days after release.

Of people living with HIV in the US, ~16 % or over 150,000 individuals passed through a correctional facility in 2006. Given the enormous impact of HIV within incarcerated populations, facilitating continuity of care from jails to the community is particularly important in reducing morbidity and mortality for releasees. Grantees participating in the Enhancing Linkages to HIV Primary Care in Jail Settings Initiative developed models for identifying HIV-positive detainees during incarceration and linking them to care following release. In this sample of 1,021 HIV-infected releasees, 79 % received clinical services and 74 % received additional community services within 30 days post-release. Our analysis found several significant factors associated with linkage including: receipt of HIV or medication education in jail, having a completed discharge plan at release, staff awareness of clients' release date, and stable housing on the 30th day post-release. In addition, a subset of participants who had both jail and community viral load assessments showed a statistically significant increase in suppressed viral load. EnhanceLink data suggest that jails may be effective settings to engage individuals in care.

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.

HIV prevention interventions for female sexual partners of injection drug users in Hanoi, Vietnam: 24-month evaluation results.

Vietnam's HIV epidemic is driven by injection drug use. Most IDUs are sexually active and may infect their female sexual partners (SPs). We implemented peer-based HIV prevention interventions for SPs in Hanoi. This paper reports on an evaluation of these interventions based on cross-sectional surveys of SPs. Our data show that this population can be reached, relationships improved, and consistent condom use increased (27% at 24 months up from 16% at 12 months: P = 0.002). Self-reported condom use at last sex was 3.5 times higher among participants in the intervention than among non-participants after controlling for selection bias, indicating a possible intervention effect. However, no significant association was found for consistent condom use in the previous 6 months. Many SPs remain at risk for HIV and interventions must promote a range of HIV prevention strategies including consistent condom use, lower risk sexual activity, and ARV treatment as prevention.

Female sexual partners of injection drug users in Vietnam: an at-risk population in urgent need of HIV prevention services.

Vietnam's HIV epidemic has been driven by injection drug use, with HIV prevalence among injection drug users (IDUs) of ~30%. Most IDUs are sexually active and may infect their female sexual partners (SPs). Male dominance in sexual decisions is deeply embedded in Vietnamese culture. There have been few HIV prevention interventions for SPs, who represent an important potential bridging population in the epidemic. We report findings from a baseline survey of SPs conducted in 2008 in Hanoi, Vietnam, where peer-based HIV prevention interventions targeting this population are now being implemented. The survey revealed HIV prevalence of 14% among SPs in Hanoi and only 27% reported condom use with their primary male partners half the time or more. About 69% of SPs were in serodiscordant or unknown HIV status relationships but condom use was not more frequent in these relationships than in concordant partnerships. Many SPs feared angry or violent responses if they requested condom use, problems that were even more likely in serodiscordant/unknown status relationships. SPs also reported limited prior access to HIV prevention services. Many SPs in Vietnam are at high risk for HIV and in need of HIV prevention interventions. However, to date, this population has been seriously underserved. Our interventions are in progress and results will be reported subsequently.

Reducing HIV infection among new injecting drug users in the China-Vietnam Cross Border Project.

OBJECTIVES: To assess an HIV prevention programme for injecting drug users (IDU) in the crossborder area between China and Vietnam. DESIGN: Serial cross-sectional surveys (0, 6, 12, 18, 24 and 36 months) of community-recruited current IDU. METHODS: The project included peer educator outreach and the large-scale distribution of sterile injection equipment. Serial cross-sectional surveys with HIV testing of community recruited IDU were conducted at baseline (before implementation) and 6, 12, 18, 24 and 36 months post-baseline. HIV prevalence and estimated HIV incidence among new injectors (individuals injecting drugs for < 3 years) in each survey wave were the primary outcome measures. RESULTS: The percentages of new injectors among all subjects declined across each survey waves in both Ning Ming and Lang Son. HIV prevalence and estimated incidence fell by approximately half at the 24-month survey and by approximately three quarters at the 36-month survey in both areas (all P < 0.01). CONCLUSION: The implementation of large-scale outreach and syringe access programmes was followed by substantial reductions in HIV infection among new injectors, with no evidence of any increase in individuals beginning to inject drugs. This project may serve as a model for large-scale HIV prevention programming for IDU in China, Vietnam, and other developing/transitional countries.

Patterns of HIV prevalence and HIV risk behaviors among injection drug users prior to and 24 months following implementation of cross-border HIV prevention interventions in northern Vietnam and southern China.

In 2002, we implemented a 4-year HIV prevention intervention for injection drug users (IDUs) in Lang Son Province, Vietnam, and Ning Ming County, Guangxi Province, China, a cross-border region seriously affected by inter-twined epidemics of heroin injection and HIV infection. The interventions involve peer education on HIV risk reduction and provision of new needles/syringes through direct distribution and pharmacy vouchers. We consider this to be a structural intervention in which risk reduction information and sterile injection equipment are diffused through the IDU populations and not limited to those who actually interact with peer educators. The evaluation of structural interventions poses complex methodological challenges. The evaluation of our interventions relies primarily on cross-sectional surveys (interviews and HIV testing) of samples of IDUs selected using a combination of targeted cluster and snowball methods. We consider this to be an appropriate, albeit imperfect, design given the study context. This paper presents analyses of data from the IDU surveys conducted just prior to implementation of the interventions and 24 months thereafter. The cross-border interventions have reached large proportions of the IDUs in the project sites, drug-related HIV risk behaviors have declined in frequency, and HIV prevalence among IDUs has been stable in China and declined in Vietnam over the 24 months since the interventions were implemented. Attribution of these positive trends to the interventions must be qualified in light of possible sampling biases and the absence of control groups. However, we believe that the structural interventions implemented by the cross-border project have played a role in stabilizing HIV prevalence among IDUs two years after they were initiated. Evidence of further diffusion of the interventions among IDUs and continued stability or decline of HIV prevalence would strengthen this case.

Tuberculosis prevention and control in large jails: a challenge to tuberculosis elimination.

BACKGROUND: This study assessed the extent to which 20 large jail systems have implemented national recommendations for tuberculosis (TB) prevention and control in correctional facilities. METHODS: Data were collected through questionnaires to jail medical directors and TB control directors, observation at the jails, and abstraction of medical records of inmates with TB disease and latent TB infection. RESULTS: Twenty percent of jail systems (4/20) had conducted an assessment of risk for TB transmission in their facilities, and 55% (11/20) monitored tuberculin skin test conversions of inmates and staff. Sixty-five percent (13/20) of jails had an aggregate record-keeping system for tracking TB status and treatment, which was usually paper based. Forty-five percent of jails (9/20) had policies to offer HIV counseling and testing to tuberculin skin test-positive patients, and 75% (15/20) screen HIV-infected inmates with chest radiographs. Three quarters of jails (15/20) had policies to always isolate patients with suspected or confirmed pulmonary TB in an airborne infection isolation room. Half of jails with airborne infection isolation rooms (6/12) conformed to Centers for Disease Control and Prevention (CDC) guidelines for monitoring negative pressure. CONCLUSIONS: Improvements are needed in conducting TB risk assessments and evaluations to determine priorities and reduce risk of transmission. Inadequate medical information systems are impeding TB control and evaluation efforts. Although HIV infection is the greatest cofactor for development of TB disease, jails have inadequate information on patients' HIV status to make informed decisions in screening and management of TB and latent TB infection. Jails need to improve the use of environmental controls.

Community attitudes toward HIV prevention for injection drug users: findings from a cross-border project in southern China and northern Vietnam.

Success of HIV prevention projects for injection drug users (IDUs) depends on the support of the communities in which they are implemented. This article presents data from cross-sectional community surveys of HIV knowledge and attitudes toward peer-based HIV prevention interventions for injection drug users in a border area of Lang Son Province, Vietnam and Ning Ming County, Guangxi Province, China. Analysis of these surveys at baseline and 18 months reveals generally high or improving levels of HIV knowledge and positive attitudes toward the interventions in both Vietnam and China. Levels of knowledge and positive attitudes tended to be higher in Vietnam than in China. Interviews with staff and peer educators suggest that the project's community education efforts have increased support for the interventions and contributed to their smooth implementation. However, the community surveys also reveal some continuing deficits in HIV knowledge and understanding of the interventions, including perceptions that provision of new needles/syringes will result in increased drug use. Additional education, including dissemination of countervailing project data, is necessary to address these deficits and further increase community support for the interventions.

Patterns of HIV prevalence among injecting drug users in the cross-border area of Lang Son Province, Vietnam, and Ning Ming County, Guangxi Province, China.

BACKGROUND: To assess patterns of injecting drug use and HIV prevalence among injecting drug users (IDUs) in an international border area along a major heroin trans-shipment route. METHODS: Cross-sectional surveys of IDUs in 5 sites in Lang Son Province, Vietnam (n = 348) and 3 sites in Ning Ming County, Guangxi Province, China (n = 308). Respondents were recruited through peer referral ("snowball") methods in both countries, and also from officially recorded lists of IDUs in Vietnam. A risk behavior questionnaire was administered and HIV counseling and testing conducted. RESULTS: Participants in both countries were largely male, in their 20s, and unmarried. A majority of subjects in both countries were members of ethnic minority groups. There were strong geographic gradients for length of drug injecting and for HIV seroprevalence. Both mean years injecting and HIV seroprevalence declined from the Vietnamese site farthest from the border to the Chinese site farthest from the border. 10.6% of participants in China and 24.5% of participants in Vietnam reported crossing the international border in the 6 months prior to interview. Crossing the border by IDUs was associated with (1) distance from the border, (2) being a member of an ethnic minority group, and (3) being HIV seropositive among Chinese participants. CONCLUSION: Reducing the international spread of HIV among IDUs will require programs at the global, regional, national, and "local cross border" levels. At the local cross border level, the programs should be coordinated on both sides of the border and on a sufficient scale that IDUs will be able to readily obtain clean injection equipment on the other side of the border as well as in their country of residence.

Correlates of HIV status among injection drug users in a border region of southern China and northern Vietnam.

This article presents an analysis of the correlates of HIV status among samples of injection drug users (IDUs) in Lang Son Province, Vietnam (n=348), and Ning Ming County, Guangxi Province, China (n=294), who were interviewed and tested for HIV antibody just before the start of a peer-based HIV prevention intervention in this border region. Participants were largely male, in their 20s, and single. Logistic regression analysis suggests that among Chinese IDUs, border-related factors (eg, living closer to the border, buying drugs across the border more frequently) and younger age are the best predictors of HIV positivity. In Vietnam, HIV status seems to drive behavior (eg, some risk reduction practices are predictive of HIV positivity). These differing patterns may reflect the fact that the intertwined epidemics of heroin injection and HIV began earlier and HIV prevalence has reached significantly higher levels in Lang Son than across the border in Ning Ming. Although border-related factors emerge as predictors in Ning Ming, more IDUs in Lang Son are HIV-positive and may be reacting behaviorally to that status. Their greater likelihood of engaging in risk reduction measures may reflect some combination of a belief that risk reduction can slow disease progression and an altruistic desire to avoid infecting others.

Smokers' responses to advertisements for regular and light cigarettes and potential reduced-exposure tobacco products.

This study examines smokers' responses to advertisements for potentially reduced exposure tobacco products (PREP), light cigarettes, and regular cigarettes. A convenience sample of 600 adult smokers reviewed one actual advertisement for each type of product. Smokers ranked the products on health risk, amount of tar, and carcinogenicity, and identified the messages they perceived the advertisements to convey. Smokers perceived PREP products as having lower health risks (mean = 5.4 on a scale of 1-10) and carcinogens (6.6) than light cigarettes (5.8 and 6.9, respectively, p < .001), and lights as having lower health risks and carcinogen levels than regular cigarettes (8.2 and 8.8, respectively, p <.001). The average PREP rating for level of tar (5.3) was not significantly less than the light mean of 5.4, but both were significantly less than the regular mean of 8.4 (p <.001). Although no advertisements explicitly said that the products were healthy or safe, advertisements for PREP products and light cigarettes were interpreted as conveying positive messages about health and safety. Most smokers believed that claims made in cigarette advertisements must be approved by a government agency. The results indicate that advertisements can and do leave consumers with perceptions of the health and safety of tobacco products that are contrary to the scientific evidence. Explicit and implicit advertising messages may be strengthened by the perceived government endorsement. This supports the Institute of Medicine's recommendation to regulate the promotion, advertising, and labeling of PREP tobacco products and light cigarettes. Effective regulation may need to focus on consumer perceptions resulting from advertisements rather than the explicit content of advertising text.