Nguyen Nguyen 1 , Onyebuchi Arah 2 and Roger Detels 2

1. Factors Associated with Methadone Maintenance Enrollment among Opioid Injecting Users and in Vietnam: A Case-Control Study Nguyen Nguyen1, OnyebuchiArah2 and Roger Detels2 1 National Institute of Hygiene and Epidemiology, Vietnam 2 Department of Epidemiology, University of California, Los Angeles Presenting author: Nguyen Nguyen, nguyenucla@gmail.com

2. The Vietnam MMT Program: Some activities...

3. Presentation outline • Introduction • Research Necessity and Objective • Study sites • Methods • Results and Discussion • Implications/Recommendations

4. INTRODUCTION:The Pilot Methadone Maintenance Treatment (MMT) Program in Vietnam • MMT: worldwide use for decades; multiple proven benefits. • 2008-2009 MMT pilot project in HaiPhong& HCMC, 3 clinics in each province, 250 patients per clinic. • High level of attention and dedicated resources from many sectors (health, public security, international organizations, mass organizations, etc). • Patients carefully selected via a multi-step reviewing process with strict admission criteria.

5. INTRODUCTION:The Pilot MMT Program in Vietnam (continued) • Integrated psycho-social counseling service; high average methadone dose (~110mg/day) • High retention: 90% after 1 year; 80% after 2 years • Low concurrent drug use: 10% at 1 year; injecting frequency is greatly reduced • All clinics full to capacity (or beyond) • April 2010: National expansion plan aiming at enrolling 80,000 DUs in 30 provinces by 2015 • May 2013: 60 MMT clinics are operating in 20 provinces with ~13,000 patients on methadone

6. Research necessity and objective • Results of the pilot MMT program => National scale-up will probably be beneficial, but: • Initial results were from a small fraction of drug users who had been carefully selected =>non-representative. • The pilot program was carried out in somewhat special conditions. • Identification of barriers and facilitators of enrollment is needed to target groups that are less likely to enroll and enhance service utilization in future. • Study objective: To identify factors associated with MMT enrollment among opioid IDUs in HaiPhong, Vietnam.

7. STUDY SITES • HaiPhong: 2 urban (urban) districts & 2 rural (less urbanized) districts randomly selected from the 4 urban & 3 rural districts where MMT clinics were operating in early 2011. • Urban and rural districts were included as two separate strata because socio-economic characteristics and other MMT-related conditions were anticipated to be different between them.

8. Why study in Hai Phong? • The province with the most MMT clinics in Vietnam (7 clinics when this study started in 2011). • Among top 3 provinces with the highest number of PLHIV in recent years: HCMC, Ha Noi and HaiPhong. • Population size (1.9 million) and work-related migration are less than those of Hanoi and HCMC.

9. Map of Hai Phong and location of the 4 selected districts Thuy Nguyen Hong Bang Le Chan An Lao

10. METHODS • Study design: Case-control study • Participants: An injecting drug user (IDU) was defined as a person who had used opoid(s) in at least 25 out of a 30-day period in the past, mainly by injection. • Case definition: A case was an IDUwho hadregistered for MMT in previous 6 months. • Control definition: A control was a current IDU who had never registered for MMT. • Exclusion criteria: Under 18yrs old; severely ill; clear signs of opioid withdrawal or poor behaviors, “trainees” of ‘06 centers.

11. METHODS (continued) • Sample size and participant selection: • 150 cases recruited anonymously via MMT clinics, local health workers and peer educators, 35-40 cases from each of the 4 districts. • 446 controls selected from 600 participants of the concurrent survey who had never registered for MMT. The survey recruited current IDUs anonymously via pharmacies and N&S programs. • Data collection technique:ACASI • Data analysis: Conditional logistic regression stratifying on district of residence (SAS 9.2) was used to derive odds ratios. Twenty-one predictors variables included in the initial regression model; 9 variables with P-value > 0.2 remained in the final model.

12. RESULTS

13. DISCUSSION • This study was conducted in a context characterized by high demand, limited access to MMT and existence of multiple administrative and logistic barriers. • Results from this study are supported by those from the related qualitative and cross-sectional studies: • Family care and financial support were important facilitators of MMT enrollment. • Longer history of injecting use, higher daily injection frequency, and more drug cessation attempts in the past were positive predictors of MMT registration (but # of times attending 06 centers was not) . • Travel time from home to MMT clinic and female gender were negative predictors of MMT enrollment • Why problematic marriage and past history of HIV testing were associated with MMT registration?

14. Implications/Recommendations for the MMT program in Vietnam • The potential barriers to MMT enrollment identified in this study need be further examined and addressed, i.e., how to improve enrollment among: • Female IDUs? • Those who live far from MMT clinics? • New IDUs? • The supportive role of family (emotional, logistical, financial,…) should be enhanced.

15. Acknowledgment The study of which results are presented herein is part of a research project implemented with financial support from the U.S. NIH via the UCLA/Fogarty AIDS International Training and Research Program (AITRP), organizational support from the Vietnam National Institute of Hygiene and Epidemiology, local health agencies and drug-user peer groups in the study districts in HaiPhong,Vietnam. Dr. Nguyen (the presenting author) was a PhD student Fellow of the Vietnam Education Foundation and a trainee in the UCLA/Fogarty AITRP during the time this study was conducted. THANK FOR YOUR ATTENTION!