Vietnam HIV Addiction Technology Transfer Center
Substance Use Disorders and HIV in
Vietnam since Doi Moi (Renovation):
An Overview
LE MINH GIANG1, LUNG BICH NGOC1, VU HUY HOANG2,
KEVIN MULVEY2, RICHARD RAWSON3
1. Vietnam-HIV Addiction Technology Transfer Center (VHATTC),
Hanoi Medical University, Vietnam
2. SAMHSA, US Embassy Hanoi
3. Integrated Substance Abuse Program, UCLA
1
Topics
1. Changing patterns of substance use and abuse
since early 1990s
2. HIV epidemic and the role of substance abuse
3. Responses to SUD and HIV: successes and gaps
4. Current research capacity and research needs
2
Most popular drugs in Vietnam
(reported drug of choice among caught users)
Drug of choice
1995
2001
2005
2012
Amphetamine-type
stimulants
N/A
3
3
2
0%
1,5%
2,5%
6,5%
2
1
1
1
1,4%
29,3%
88,6%
84,7%
1
2
2
3
92,7%
66,8%
27,8%
6,4%
Heroin
Opium
Source: DSEP/MoLISA (1995, 1999, 2001, 2005); National Commission on
AIDS, Drug and Prostitution (2012).
3
Increasing both heroin and Methamphetamine
Source: UNODC (2012b)
4
Frequency of using Methamphetamine
the last 90 days
Several times per week
Several times per month
14.5%
Once per week
Once or twice in last 90 days
11.2%
17.0%
26.7%
33.6%
46.9%
44.3%
43.6%
31.4%
47.7%
15.7%
16.9%
37.5%
20.6%
13.8%
8.7%
39.6%
25.0%
20.6%
HEROIN
USERS
MSM
Source: UNODC (2012a)
26.7%
FSWS
10.9%
4.7%
25.5%
ATS USERS
TAXI
DRIVERS
16.9%
BAR GOERS
5
Concurrent use of heroin and other drugs
Heroin users in a 2012 survey reported using the a wide
range of other drugs in the past 12 months
15%
7.0%
Crystal Meth
Marijuana
Source: PSI (2012): BS Survey
2.8%
3.0%
Amphetamine
All others (Pipolpen,
Opium…)
6
Drug use prevalence among FSW
Ever used drugs (NIHE IBBS 2009)
7
Drug use risk among FSW
Illicit drug use (lifetime)
Never used
High HIV prevalence
provinces
Adjusted
95% CI
OR*
Low HIV prevalence
provinces
Adjusted
95% CI
OR**
1
—
1
—
Non-injecting drug use only
1.73
1.17, 2.56
2.32
0.78, 6.92
Injecting drug use
3.18
2.25, 4.49
26.07
14.38, 47.27
* 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)
8
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
9
Number of new infections
Projection of HIV transmission in Viet Nam to 2015
30,000
25,000
20,000
15,000
10,000
5,000
0
IDU
FSW
Client
Low Risk Female
Source: MOH (2012) EPP 2011 - 2015
Low Risk Male
10
Share of injecting drug use among HIV reported
100.0%
90.0%
2.6%
3.0%
2.8%
3.2%
3.8%
5.3%
8.1%
13.1%
80.0%
16.9%
19.4%
22.5%
24.7%
70.0%
38.9%
60.0%
51.1%
45.1%
42.5%
40.5%
36.6%
49.5%
45.3%
50.0%
45.0%
40.0%
1.3%
0.8%
43.9%
41.8%
37.7%
0.6%
30.0%
1.4%
0.9%
1.3%
20.0%
1.6%
1.5%
0.5%
0.6%
2009'
2010'
0.8%
0.6%
2011'
2012'
10.0%
0.0%
2001'
Không rõ
2002'
Khác
2003'
STDs
2004'
Lao
2005'
Gái MD
2006'
Nghi AIDS
2007'
NCMT
Source: VAAC (2012)
2008'
Tình dục khác giới
Các nhóm còn lại
11
Vietnam IDU-HIV Twin Epidemics
IDU Population
(n=336,000)
26% of IDU HIVinfected
(1-56% by province)
HIV-infected Population
(n=248,245)
62% report history of
IDU at ART initiation
MOH (2012) 2009 – 2010 IBBS Results; VAAC (2013) Annual report; Nguyen (2013) – Courtesy
of Dr. Todd Korthuis
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
80
70
HIV prevalence (%)
60
50
40
30
20
10
0
Hanoi 1
Quang Ninh
Nghe An
North West
An Giang
Can Tho
Hai Phong
HCMC - Young IDUs
HCMC-Old IDUs
National prevalence
Source: MOH (2012) EPP 2011 - 2015
13
Map of HIV prevalence among IDUs in Vietnam
(2011)
Source: MOH (2012)
14
Prevalence of HBV and HCV infection among
high risk groups in 2009
HBs Ag (+)
IDU
MSM
SSW
VSW
Mean
15.1
15.9
11.7
11.2
Median
14.7
12.3
10.8
10.8
12.1-16.8
11.0-20.7
9.7-12.0
8.4-13.3
Mean
58.7
45.1
55.6
46.1
Median
59.5
45.2
56.6
47.9
53.5-64.2
40.0-49.7
52.6-62.7
37.3-52.2
Mean
58.0
26.1
n/a
n/a
Median
57.4
24.8
n/a
n/a
44.7-75.6
17.3-34.8
n/a
n/a
IQR
HBs Ag (-) &
Anti-HBC (+)
IQR
HCV Ag/Ab (+)
IQR
Source: 2009 – 2010 IBBS Results
15
Current or previous infection of HCV
among IDUs in 2009
100.0
90.0
80.0
70.0
%
60.0
50.0
40.0
30.0
20.0
10.0
0.0
ALL
AG
CT
DI
DN
HCM
HN
Source: 2009 – 2010 IBBS Results
HP
NA
QN
YB
16
HCV prevalence since first injection (2006)
Source: Clatts et al. (2009)
17
Needle and syringe sharing (2009)
Proportion of IDU reporting needle and syringe sharing
Source: MOH (2012) 2009 – 2010 IBBS Results
18
Reported condom use at last sex
by age group (2009)
%
100
80
79
78
77
66
70
64
60
52
54
51
Total
<25 yr
25+ yr
40
20
0
Total
<25 yr
25+ yr
FSWs
(with most recent client)
Total
<25 yr
25+ yr
MSM
(anal sex with male partner)
Source: www.aidsdatahub.org
Male IDUs
(at last sex)
19
Reported condom use over the past 12 months
(comparing 2006 and 2009)
Source: MOH (2012) 2009 – 2010 IBBS Results
20
Projected number of adults aged 15 and older
living with HIV, by sex
21
Source: MOH (2007) EPP to 2012
Women’s exposure to HIV from their IDU
partners
IDU with a
wife:40.4%
Married &
HIV(+):
12.3%
HIV(+)
IDU:28.0%
All male IDU: 192,406
22
Courtesy of Lam et al (2012)
Estimate of IPT magnitude - IDU partners
Women tested at
VCT, 2006-2010:
110,277
All women
exposed to IDU
positive partners:
23,666
Undetected
IPT
Exposed to
IDU partners
and tested
negative at
VCT =
13,406
Courtesy of Lam et al (2012)
HIV cases
detected in
women
attributable to
IDU partners
= 1,739
Women with
personal or
other risk
exposures
23
HIV testing: comparing 2006 and 2009 IBBS
0
20
2006
40
60
80
%
100
FSWs
15
2009
35
2006
MSM
16
Male IDUs
2009
2006
2009
19
2012: 31.27% of IDUs have
tested and returned for HIV
testing result in the last 12
months
11
18
Source: www.aidsdatahub.org; NIHE (2012) Results of HSS+
24
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%
19 %
48,230 retained in care 24 mo
?%
VAAC (2013) Annual report;
? suppressed
IDU vs. non-IDU Initiating ART in Vietnam
IDU
Non-IDU
CD4 count < 50
40.1%
32.3%
WHO stage III/IV
82.7%
68.4%
TB
16.2%
10.0%
HCV
52.6%
18.1%
Alive & retained on ART
12 months
24 months
36 months
48 months
81.5%
73.6%
67.4%
63.3%
90.1%
88.2%
88.2%
85.7%
Nguyen et al (2013)
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)
27
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)
28
From “social evil” to “patient”: shifting
discourse and action
• Drug use was considered as “social evil” (tệ nạn xã
hội): 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)
29
Impacts of needle and syringe coverage
2005 - 2009
Source: VAAC, UNW, UNAIDS, PEMA (2010)
30
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/FHI 360 (50 PEPFAR-funded clinics)
– MoH/VAAC request to PEPFAR for TA
Support in 30 provinces and for all programs
31
Changes in QoL of HIV+ methadone users
Source: Tran BX et al.2012
32
HIV Rates in MMT in 2012
20 Cities/Provinces
3,500
3,000
16.9%
HIV+ Positive
2,500
HIV- Negative
2,000
1,500
?? %
1,000
46.4%
500
0
Source: VAAC (2012); Courtesy of Dr. Banys
33
477 HIV related peer-reviewed publications
2005 - 2011
Studies
80
74
Total publication on IDUs: 81/477 (17%)
70
HIV positive
60
IDUs
FSWs
50
MSM
Combination of high risk group
40
Anternatal/MCT
29
30
20
10
31
Spouses of PLHIV
Mobile population
Clients of FSWs
22
14
7
15
8
14
10
10
11
Spouses of IDUs
Minority
Young people
Clients of health care services
0
Government health officials
The general population
Others
Source: CDC & FHI (2012)
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
35
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? costeffectivness?
36
ACTIVE NIH-FUNDED STUDIES RELATED TO HIV
AND DRUG USE IN VIETNAM
Topic
Institution
Institution
country
collaboration
Year
Male IDUs in Vietnam: Ethnoepidemiology of HIV risk
University of Puerto Hanoi Medical
Rico (PI: Michael
University
Clatts)
2003-2008
HIV infection in drug users in two
international sites
Tufts University
(PI: Sherwood
Gorbach)
National Institute
of Infectious &
Tropical Diseases
2006-2010
Feasibility of pharmacy-based HIV
intervention among IDUs: Ha Giang,
Vietnam
ABT Associates
(PI: Seligman)
Ha Giang
Provincial Health
Centre
2009-2010
Diffusion of HIV1 among MSWs in SE
ASIA
University of Puerto Hanoi Medical
Rico (PI: Michael
University
Clatts)
2007-2011
Prevention for positives: RCT among
Vietnamese with HIV
JHU (PI: Vivian Go) Thai Nguyen
Centre for
Preventive
Medicine
2007 – 2011
ACTIVE NIH-FUNDED STUDIES RELATED TO HIV
AND DRUG USE IN VIETNAM
Topic
Institution
Institution
country
collaboration
Year
National Institute
of Hygiene and
Epidemiology
2010 – 2011
Development of Family Intervention
to Address drug use and HIV in
Vietnam
UCLA (PI: Li Li)
Seek, test, treat strategies for
Vietnamese drug users: A random
controlled trial
Johns Hopkins
University (PI: Quan, Vu
Minh)
Implementation of a sexual health
intervention for YMSM in two
Vietnamese cities
National Development &
Research Institutes
(PI: Goldsamt Lloyd)
Hanoi Medical
University
2012-2017
Enhancing the role of commune
health workers in HIV and drug
control in Vietnam
UCLA (PI: Li Li)
National Institute
of Hygiene and
Epidemiology
2012-2017
A pilot implementation project of
methadone and suboxone for
injecting drug users
University of
Pennsylvania (PI:
O’Brien, Charles P)
Esther and
HCMC AIDS
Committee
2012-2017
2010-2015
Many important publications (selected)
39
Vietnam-HIV Addiction Technology Transfer Center
THANK YOU FOR YOUR ATTENTION
AND SUPPORT
40
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•
•
•
•
•
•
•
•
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43
(2013)