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Substance Use Disorders and HIV in Vietnam since  Doi Moi  (Renovation): An Overview

Vietnam HIV Addiction Technology Transfer Center. Substance Use Disorders and HIV in Vietnam since  Doi Moi  (Renovation): An Overview LE MINH GIANG 1 , LUNG BICH NGOC 1 , VU HUY HOANG 2 , KEVIN MULVEY 2 , RICHARD RAWSON 3

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Substance Use Disorders and HIV in Vietnam since  Doi Moi  (Renovation): An Overview

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  1. Vietnam HIV Addiction Technology Transfer Center Substance Use Disorders and HIV in Vietnam since DoiMoi (Renovation): An Overview LE MINH GIANG1, LUNG BICH NGOC1, VU HUY HOANG2, KEVIN MULVEY2, RICHARD RAWSON3 Vietnam-HIV Addiction Technology Transfer Center (VHATTC), Hanoi Medical University, Vietnam SAMHSA, US Embassy Hanoi Integrated Substance Abuse Program, UCLA

  2. Topics • Changing patterns of substance use and abuse since early 1990s • HIV epidemic and the role of substance abuse • Responses to SUD and HIV: successes and gaps • Current research capacity and research needs

  3. Most popular drugs in Vietnam (reported drug of choice among caught users) Source: DSEP/MoLISA(1995, 1999, 2001, 2005); National Commission on AIDS, Drug and Prostitution (2012).

  4. Increasing both heroin and Methamphetamine Source: UNODC (2012b)

  5. Frequency of using Methamphetamine the last 90 days Source: UNODC (2012a)

  6. Concurrent use of heroin and other drugs Source: PSI (2012): BS Survey

  7. Drug use prevalence among FSW Ever used drugs (NIHE IBBS 2009)

  8. Drug use risk among FSW * Adjusted for age, condom use, where meet clients, and province ** Adjusted for marital status, condom use, knowledge, where meet clients, and province “Injecting drug use is the key risk factor of HIV infection among FSW in Vietnam, and attention needs to be paid especially to FSW in provinces with newer epidemics” (MOH 2012) Source: MOH (2012) 2009 -2010 IBBS results; Courtesy of Linh-Vi Le (CDC, 2013)

  9. Summary 1: Changing patterns past two decades • Mostly men1,5, • And yet drug use among FSWs has driven the HIV epidemic in this population 4,5 • Heroin are the most used: 65% - 85%1,5 ; • Mean interval of transition from heroin smoking to injection was 2.5 years3 and became increasingly shorter among heroin initiates3,4. • ATS consumption has rapidly increased after 20082. Source: 1.Do et al. 2012; 2.UNODC 2012; 3. Clatts et al.2011; 4.Thao et al. 2006; 5.Tam T.M Nguyen et al. 2012

  10. Projection of HIV transmission in Viet Nam to 2015 Source: MOH (2012) EPP 2011 - 2015

  11. Share of injecting drug use among HIV reported Source: VAAC (2012)

  12. IDU Population (n=336,000) HIV-infected Population (n=248,245) 26% of IDU HIV-infected (1-56% by province) 62% report history of IDU at ART initiation Vietnam IDU-HIV Twin Epidemics MOH (2012) 2009 – 2010 IBBS Results; VAAC (2013) Annual report; Nguyen (2013) – Courtesy of Dr. Todd Korthuis

  13. Projection of HIV prevalence among IDUs • to 2015 • HIV prevalence among IDU at national level is approximately 30%1 • The epidemic among IDU in Northwestern region is speedily rising1 Source: MOH (2012) EPP 2011 - 2015

  14. Map of HIV prevalence among IDUs in Vietnam (2011) Source: MOH (2012)

  15. Prevalence of HBV and HCV infection among high risk groups in 2009 Source: 2009 – 2010 IBBS Results

  16. Current or previous infection of HCV among IDUs in 2009 Source: 2009 – 2010 IBBS Results

  17. HCV prevalence since first injection (2006) Source: Clatts et al. (2009)

  18. Needle and syringe sharing (2009) • Proportion of IDU reporting needle and syringe sharing • Source: MOH (2012) 2009 – 2010 IBBS Results

  19. Reported condom use at last sex • by age group (2009) Source: www.aidsdatahub.org

  20. Reportedcondom use over the past 12 months (comparing 2006 and 2009) Source: MOH (2012) 2009 – 2010 IBBS Results

  21. Projected number of adults aged 15 and older living with HIV, by sex Source: MOH (2007) EPP to 2012

  22. Women’s exposure to HIV from their IDU partners HIV(+) IDU:28.0% Married & HIV(+): 12.3% IDU with a wife:40.4% All male IDU: 192,406 Courtesy of Lam et al (2012)

  23. Estimate of IPT magnitude - IDU partners Women tested at VCT, 2006-2010: 110,277 All women exposed to IDU positive partners: 23,666 Exposed to IDU partners and tested negative at VCT = 13,406 HIV cases detected in women attributable to IDU partners = 1,739 Women with personal or other risk exposures Undetected IPT Courtesy of Lam et al (2012)

  24. HIV testing: comparing 2006 and 2009 IBBS 2012: 31.27% of IDUs have tested and returned for HIV testing result in the last 12 months Source: www.aidsdatahub.org; NIHE (2012) Results of HSS+

  25. Vietnam HIV Care Cascade Out of 248,485 Vietnamese Living with HIV… 197,335 know they are infected 79% 72,213 linked to care 29% 60,924 receive ART 25% 48,230 retained in care 24 mo 19 % ? suppressed ? % VAAC (2013) Annual report;

  26. IDU vs. non-IDU Initiating ART in Vietnam Nguyen et al (2013)

  27. Adherence to ART among IDUs vs. non-IDU • Patients who are IDUs were significantly poorer in retention than non-IDUs Source: Nguyen et al(2013)

  28. Alcohol abuse among HIV positive drug users during ART • A large sample drawn from OPCs and hospitals in three cities: 30.1% reported hazardous drinking and 22.3% binge drinking • Among HIV positives who were on ART, drug users (DUs) had higher alcohol consumption and likelihood of alcohol use disorders (1.27 times) than non-Dus • DUs in the 1st year ART had higher alcohol consumption and possibility of at-risk drinking than DUs who were on waiting list • HIV positive DUs who were receiving Methadone were less likely to be at-risk drinking (0.56 times) Source: Tran X. Bach et al. (2013)

  29. From “social evil” to “patient”: shifting discourse and action • Drug use was considered as “social evil” (tệnạnxãhội): Drug users needed re-education and rehabilitation. • 1993: The Resolution 06/CP gave birth to Compulsory Centers (06 centers); • New discourse since about 2006: drug users as patients, removing drug use behavior from the Penal code in 2009 • Methadone was piloted in 2008 and then scale up • And yet more than 120 compulsory centers with the capacity of about 70,000 drug users are maintained Source: Thu Vuong et al (2012)

  30. Impacts of needle and syringe coverage 2005 - 2009 Source: VAAC, UNW, UNAIDS, PEMA (2010)

  31. MMT National Scale-Up: Status and Plan • Current MMT program • 20 provinces • 59 clinics, 1 satellite • 12,292 (through December 2012) • Implementation Landscape: 60 Clinics • USAID: SMART TA: 17 • CDC: LifeGap 16 HCMC 03 • Global Fund & WB, HAARP: 24 • Provincial Requests for 58 new clinics to open in 2013 • Technical Assistance (TA) landscape: • CDC/FHI360 (50 PEPFAR-funded clinics) • MoH/VAAC request to PEPFAR for TA Support in 30 provinces and for all programs

  32. Changes in QoL of HIV+ methadone users Source: Tran BX et al.2012

  33. HIV Rates in MMT in 2012 20 Cities/Provinces ?? % 46.4% Source: VAAC (2012); Courtesy of Dr. Banys

  34. 477 HIV related peer-reviewed publications 2005 - 2011 Studies

  35. Summary 2: Lots of successes; remained key challenges • Changing patterns of drug use and abuse: • Heroin and HIV epidemic moving rapidly to remote provinces • ATS use on the rise in urban settings, most problematic among MSM, FSW and methadone patients (threat to success) and yet lack real data • Expansion of methadone program with endorsement by the government (Degree 96 in November 2012) • Challenges in maintaining high quality • Challenges in settings and individuals not ready for MMT • Cascade of IDUs access to HIV services (testing, registered to care, OPC, retention in ARV) • Lack of integration of addiction and HIV services

  36. Research needs in Vietnam • How to improve integration of SUD and HIV services • What are and how to introduce other alternatives to MMT, especially for settings and individuals out-of-reach with MMT • How to reach IDU at critical junctures where they are most vulnerable and yet have better chance to be connected to services (e.g. before release from 06 centers) • How to address epidemics among other highly vulnerable groups: women partners of IDUs (esp. MMT clinics are opening up this opportunity), female sex workers, MSM • How to capture and understand better changing epidemics, e.g. ATS and HIV linkage; changing patterns of drug use, especially injection risks • What is the shape of future workforce: role of professionals? role of para-professionals? cost-effectivness?

  37. ACTIVE NIH-FUNDED STUDIES RELATED TO HIV AND DRUG USE IN VIETNAM

  38. ACTIVE NIH-FUNDED STUDIES RELATED TO HIV AND DRUG USE IN VIETNAM

  39. Many important publications (selected)

  40. Vietnam-HIV Addiction Technology Transfer Center THANK YOU FOR YOUR ATTENTION AND SUPPORT

  41. References • CDC and FHI360. HIV and AIDS publications 2005 – 2011: Quick reference guide for national research agenda. 2012. • Clatts MC, Colón-López V, Giang LM, Goldsamt LA. Prevalence and incidence of HCV infection among vietnam heroin users with recent onset of injection. Journal of Urban Health. 2010;87(2):278-291. • Clatts MC, Goldsamt LA, Minh Giang L, Colón-López V. Accelerated transition to injection among male heroin initiates in hanoi, vietnam: Implications for early harm reduction interventions. J Community Health. 2011;36(6):999-1003. • Do K, Minichiello V, Hussain R. HIV risks among injecting drug users in vietnam: A review of the research evidence. Current HIV Research. 2012;10(6):479-486. • Hammett TM, Wu Z, Duc TT, et al. ‘Social evils’ and harm reduction: The evolving policy environment for human immunodeficiency virus prevention among injection drug users in china and vietnam. Addiction. 2008;103(1):137-145. • Hien NT, Giang LT, Binh PN, Deville W, van Ameijden EJ, Wolffers I. Risk factors of HIV infection and needle sharing among injecting drug users in ho chi minh city, vietnam. J Subst Abuse. 2001;13(1):45-58. • Ministry of Health. Results from the HIV/STI integrated biological and behavioral surveillance (IBBS) in vietnam, round II —2009. 2012. • Jardine M, Crofts N, Monaghan G, Morrow M. Harm reduction and law enforcement in vietnam: Influences on street policing. Harm Reduction Journal. 2012;9(1):27.

  42. Jardine M, Khuat TH. Case study: Methadone maintenance treatment in hanoi, vietnam. Harm Reduction Journal. 2012;9(1):26. • Lam NT. Drugs, sex and AIDS: Sexual relationships among injecting drug users and their sexual partners in vietnam. Culture, health & sexuality. 2008;10(S1):123-137. • Maher L, Coupland H, Musson R. Scaling up HIV treatment, care and support for injecting drug users in vietnam. International Journal of Drug Policy. 2007;18(4):296-305. • MOH/VAAC. Vietnam HIV/AIDS estimates and projection 2011 – 2015. 2012. • Ngo AD, Schmich L, Higgs P, Fischer A. Qualitative evaluation of a peer-based needle syringe programme in vietnam. International Journal of Drug Policy. 2009;20(2):179. • Nguyen T, Nguyen LT, Pham MD, Vu HH, Mulvey KP. Methadone maintenance therapy in vietnam: An overview and scaling-up plan. Advances in preventive medicine. 2012;2012. • Nguyen VT, Scannapieco M. Drug abuse in vietnam: A critical review of the literature and implications for future research. Addiction. 2008;103(4):535-543. • Nguyen DB, Do NT, Shiraishi RW, et al. Outcomes of antiretroviral therapy in vietnam: Results from a national evaluation. PloS one. 2013;8(2) • Reid G, Higgs P. Vietnam moves forward with harm reduction: An assessment of progress. Global public health. 2011;6(2):168-180. • Thao LTL, Lindan CP, Brickley DB, Giang LT. Changes in high-risk behaviors over time among young drug users in south vietnam: A three-province study. AIDS and Behavior. 2006;10:47-56.

  43. Tran BX, Ohinmaa A, Duong AT, et al. Changes in drug use are associated with health-related quality of life improvements among methadone maintenance patients with HIV/AIDS. Quality of Life Research. 2012;21(4):613-623. • Tran BX, Nguyen N, Ohinmaa A, et al. Prevalence and correlates of alcohol use disorders during antiretroviral treatment in injection-driven HIV epidemics in vietnam. Drug Alcohol Depend. 2012. • Tran TN, Detels R, Hien NT, Long HT, Nga PTH. Drug use, sexual behaviours and practices among male drug users in hanoi, Vietnam—a qualitative study. International Journal of Drug Policy. 2004;15(3):182-188. • Tran TN, Detels R, Long HT, Lan HP. Drug use among female sex workers in hanoi, vietnam. Addiction. 2005;100(5):619-625. • Tuan NA, Hien NT, Chi PK, et al. Intravenous drug use among street-based sex workers: A high-risk behavior for HIV transmission. Sex Transm Dis. 2004;31(1):15-19. • Vuong T, Ali R, Baldwin S, Mills S. Drug policy in vietnam: A decade of change? International Journal of Drug Policy. 2011;23:319-326. • UNODC. Amphetamine-type Stimulants in Vietnam: Review of availability, use and implications for health and security. 2012 • www.aidsdatahub.org (accessed April 02, 2013) • Various annual reports from National Commission on AIDS, Drugs and Prostitution (2012); DSEP/MoLISA (1995, 1999, 2001, 2005); VAAC (2012) • Courtesy of presentation by Linh-vi Le (CDC, 2013); PSI (2012): BS Survey; Todd Korthuis (2013)

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