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

Prevalence of HIV, risk behaviours and vulnerabilities of female sex partners of the HIV positive people who inject drugs (PWID) in Dhaka city, Bangladesh

Background

The HIV epidemic in Bangladesh is largely being driven by people who inject drugs (PWID) and mainly concentrated in Dhaka city. Intregrated biological and behavioural survey (IBBS) data of 2016 showed that a considerable percentage of the HIV positive PWID had unsafe sex with their female sex partners. Prevalence of HIV, risk behaviorus and vulnerabilities among the female sex partners of the PWID still remain unexplored.

Methods

To measure HIV prevalence, risk behaviours (drugs/injection/sexual) and vulnerabilities (treatment of and knowledge of sexually transmitted infections (STIs) and HIV/uptake of the routine HIV testing and HIV prevention services/physical and sexual violence), a quantitative survey was conducted among 227 female sex partners of the HIV positive PWID in Dhaka city in 2019 by adopting a take-all sampling technique.

Results

The median age of participants was 34.0 years. Prevalence of HIV was 16.7% (95% CI: 12.4–22.2). Only 6.8% to 18.7% of the participants used condoms consistently with different male sex partners; only 6.8%cto 18.7% during last year. Seventy five percent (95% CI: 69.2–80.8) had no knowledge on STI symptoms. Self-reported symptoms of STIs were reported by 26% (95% CI: 20.7–32.1) and half sought treatment during last year. Nineteen percent (95% CI: 14.7–25.1) had comprehensive knowledge of HIV. As part of the routine HIV prevention services by the PWID drop-in-centres (DICs), 42.7% (95% CI: 36.4–49.3) of the participants were tested for HIV and knew their result within the last year. One-third never received HIV prevention services. During the last one year preceding the survey, 46% (95% CI: 39.3–52.6) reported been beaten and 20.2% (95% CI: 15.3–26.1) been raped.

Conclusion

It is urgently necessary to consider the high-risk behaviours and vulnerabilities in designing or to strengthen targeted interventions for female sex partners of the HIV positive PWID in Dhaka city to ensure equality in accessing and utilization of services.

Prevalence of HIV, risk behaviours and vulnerabilities of female sex partners of the HIV positive people who inject drugs (PWID) in Dhaka city, Bangladesh

BACKGROUND

The HIV epidemic in Bangladesh is largely being driven by people who inject drugs (PWID) and mainly concentrated in Dhaka city. Intregrated biological and behavioural survey (IBBS) data of 2016 showed that a considerable percentage of the HIV positive PWID had unsafe sex with their female sex partners. Prevalence of HIV, risk behaviorus and vulnerabilities among the female sex partners of the PWID still remain unexplored.

METHODS

To measure HIV prevalence, risk behaviours (drugs/injection/sexual) and vulnerabilities (treatment of and knowledge of sexually transmitted infections (STIs) and HIV/uptake of the routine HIV testing and HIV prevention services/physical and sexual violence), a quantitative survey was conducted among 227 female sex partners of the HIV positive PWID in Dhaka city in 2019 by adopting a take-all sampling technique.

RESULTS

The median age of participants was 34.0 years. Prevalence of HIV was 16.7% (95% CI: 12.4-22.2). Only 6.8% to 18.7% of the participants used condoms consistently with different male sex partners; only 6.8%cto 18.7% during last year. Seventy five percent (95% CI: 69.2-80.8) had no knowledge on STI symptoms. Self-reported symptoms of STIs were reported by 26% (95% CI: 20.7-32.1) and half sought treatment during last year. Nineteen percent (95% CI: 14.7-25.1) had comprehensive knowledge of HIV. As part of the routine HIV prevention services by the PWID drop-in-centres (DICs), 42.7% (95% CI: 36.4-49.3) of the participants were tested for HIV and knew their result within the last year. One-third never received HIV prevention services. During the last one year preceding the survey, 46% (95% CI: 39.3-52.6) reported been beaten and 20.2% (95% CI: 15.3-26.1) been raped.

CONCLUSION

It is urgently necessary to consider the high-risk behaviours and vulnerabilities in designing or to strengthen targeted interventions for female sex partners of the HIV positive PWID in Dhaka city to ensure equality in accessing and utilization of services.

Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs)

BACKGROUND

Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design.

OBJECTIVES

The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research.

METHODS

This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added.

SELECTION CRITERIA

To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes.

RESULTS

This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied.

CONCLUSION

This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.

Peer education for HIV prevention among high-risk groups: a systematic review and meta-analysis

Background

Peer education has become a strategy for health promotion among high-risk groups for HIV infection worldwide. However, the extent to which peer education could have an impact on HIV prevention or the long-term effect of this impact is still unknown. This study thus quantifies the impact of peer education over time among high-risk HIV groups globally.

Method

Following the PRISMA guidelines, a systematic review and meta-analysis was used to assess the effects and duration of peer education. A thorough literature search of PubMed, Web of Science, Embase and Cochrane Library was performed, and studies about peer education on high-risk HIV groups were reviewed. Pooled effects were calculated and the sources of heterogeneity were explored using meta-regression and subgroup analysis.

Results

A total of 60 articles with 96,484 subjects were identified, and peer education was associated with 36% decreased rates of HIV infection among overall high risk groups (OR: 0.64; 95%CI: 0.47–0.87). Peer education can promote HIV testing (OR = 3.19; 95%CI:2.13,4.79) and condom use (OR = 2.66, 95% CI: 2.11–3.36) while reduce equipment sharing (OR = 0.50; 95%CI:0.33,0.75) and unprotected sex (OR = 0.82; 95%CI: 0.72–0.94). Time trend analysis revealed that peer education had a consistent effect on behavior change for over 24 months and the different follow-up times were a source of heterogeneity.

Conclusion

Our study shows that peer education is an effective tool with long-term impact for behavior change among high-risk HIV groups worldwide. Low and middle-income countries are encouraged to conduct large-scale peer education.

High HIV Prevalence and Associated Risk Factors Among Female Sexual Partners of Male Injection Drug Users (MWID) in Ho Chi Minh City, Vietnam

Injection drug use is a major factor in acquiring and transmitting HIV in Vietnam. This analysis aims to present estimates of HIV infection and factors associated with HIV infection among female sex partners (FSP) of MWID in Ho Chi Minh City (HCMC), Vietnam. Cross-sectional surveys were conducted in 2011 and 2013 among males who inject drugs (MWID) who then referred their FSP for a behavioral and biologic survey. In total, 445 MWID and FSPs were enrolled. HIV prevalence among MWID was 50 and 35 % among FSPs. Among FSPs, 60.3 % reported ever using illegal drugs and among those, 72.7 % reported ever injecting illicit drugs. Among FSP, injection drug for >1 year [adjusted Odds Ratio (aOR), 95 % CI 2.94, 1.19-7.26), p value = <0.001] and having a male partner infected with HIV [(aOR 3.35: 1.97-5.69), p value = <0.001] were associated with HIV infection. The prevalence of HIV infection is high among FSP of MWID in HCMC and is highly associated with the injection drug use behavior of the FSP. Harm-reduction intervention programs that focus on the MWID-FSP couple or directly on the FSPs are required.

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.

Women, drugs and HIV

BACKGROUND

Women who use drugs, irrespective of whether these are injected or not, are faced with multiple issues which enhance their vulnerability to HIV.

METHODS

In this commentary, we explore the HIV risks and vulnerabilities of women who use drugs as well as the interventions that have been shown to reduce their susceptibility to HIV infection.

RESULTS

Women who inject drugs are among the most vulnerable to HIV through both unsafe injections and unprotected sex. They are also among the most hidden affected populations, as they are more stigmatized than their male counterparts. Many sell sex to finance their own and their partner's drug habit and often their partner exerts a significant amount of control over their sex work, condom use and injection practices. Women who use drugs all over the world face many different barriers to HIV service access including police harassment, judgmental health personnel and a fear of losing their children.

CONCLUSION

In order to enable these women to access life-saving services including needle-syringe and condom programs, opioid substitution therapy and HIV testing and treatment, it is essential to create a conducive environment and provide tailor-made services that are adapted to their specific needs.

Systematic assessment of condom use measurement in evaluation of HIV prevention interventions: need for standardization of measures

When evaluating HIV prevention interventions, condom use is a common outcome measure used to assess changes in HIV-related behaviors; however, no widely accepted standards exist for its measurement. Using systematic review data on HIV prevention interventions conducted in low- and middle-income countries, we examined trends in condom use measurement since 1990. We abstracted data from standardized forms on six dimensions of condom use: partner type, temporal period, measurement scale, consistency, controlling for abstinence, and type of sex. Of 215 studies reviewed, 109 studies (51 %) measured condom use as a primary outcome. Outcomes were stratified by partner type in 47 studies (43 %). Assessing condom use at last sex was the most common measurement. Consistency of condom use was assessed in 47 studies (43 %). Developing and utilizing standards for condom use measurement would increase comparability of findings across studies and benefit HIV prevention research. Recommendations include measuring condom use at last sex, frequency of condom use, and number of protected sex acts in studies evaluating the efficacy of behavioral interventions on sexual risk behavior.

Challenges facing HIV-positive persons who use drugs and their families in Vietnam

It is hypothesized that persons who use drugs (PWUD) in Vietnam who are also HIV-positive may face additional challenges in psychosocial outcomes, and these challenges may extend to their family members. In this study, we examined depressive symptoms, stigma, social support, and caregiver burden of HIV-positive PWUD and their family members, compared to the outcomes of HIV-negative PWUD and their family members. Baseline, 3-month, and 6-month assessment data were gathered from 83 PWUD and 83 family members recruited from four communes in Phú Thọ Province, Vietnam. For PWUD, although we observed a general decline in overall stigma over time for both groups, HIV-positive PWUD consistently reported significantly higher overall stigma for all three periods. Depressive symptoms among family members in both groups declined over time; however, family members of HIV-positive PWUD reported higher depressive symptoms across all three periods. In addition, family members of HIV-positive PWUD reported lower levels of tangible support across all three periods. Caregiver burden among family members of HIV-positive PWUD increased significantly over time, whereas the reported burden among family members of HIV-negative PWUD remained relatively unchanged. The findings highlight the need for future interventions for PWUD and family members, with targeted and culturally specific strategies to focus on the importance of addressing additional stigma experienced by PWUD who are HIV-positive. Such challenges may have direct negative impact on their family members' depressive symptoms, tangible support, and caregiver burden.

Addressing the needs of sexual partners of people who inject drugs through peer prevention programs in Iran

Despite the fact that HIV epidemic is mainly driven by injection drug use in Iran, partners of People Who Inject Drugs (PWID) have been seriously neglected in terms of effective preventive interventions. Currently, sexual partners of PWID might have access to some harm reduction services at Voluntary Counselling and Testing (VCT) centers; however, their needs have not been effectively targeted and met. Unfortunately, the current programs implemented by the Ministry of Health have overlooked the importance of this population in the course of the HIV epidemic throughout the country. In this policy brief, we are trying to draw the health policy-makers' attention to this overlooked population and while reviewing the advantages and disadvantages of some of the readily available options on the table, come up with a recommended action to tackle this problem. Our recommended action that seems to have had promising results elsewhere in Asia would try to implement preventive interventions targeting this particular population through peer prevention programs.

Correlated outcomes of a pilot intervention for people injecting drugs and their family members in Vietnam

BACKGROUND

The interrelationship between the well-being of injecting drug users (IDUs) and their family environment has been widely documented. However, few intervention programs have addressed the needs of both IDUs and their family members.

METHODS

This study describes a randomized intervention pilot targeting 83 IDUs and 83 of their family members from four communes in Phú Thọ province, Vietnam. The IDUs and family members in the intervention condition received multiple group sessions, with the intent to improve psychological well-being and family relationships. The intervention outcomes (depressive symptoms and family relations) were evaluated at baseline, 3-month and 6-month follow-up assessments.

RESULTS

Depressive symptoms and family relations reported by IDUs were found to be correlated to those reported by their family members. Overall, significant intervention effects on depressive symptoms and family relations were observed for both IDUs and family members. A similar improvement pattern in family relations emerged for both the IDU and family member samples, although the intervention effect of reducing depressive symptoms was more sustainable for family members at the 6-month assessment when compared to the IDU sample.

CONCLUSION

The intervention pilot addressed challenges faced by IDUs and their family members and revealed correlated outcomes for the two groups. Findings suggest a vital need to include family members in future drug prevention and harm reduction intervention efforts.

An intervention to improve mental health and family well-being of injecting drug users and family members in Vietnam

Family plays an important role in the lives of injecting drug users (IDUs) in Vietnam. This study examined the preliminary outcomes of an intervention targeting IDUs and their family members in Vietnam. Eighty-three families, including 83 IDUs and 83 family members, were recruited from 4 communes in Phú Tḥo Province, Vietnam. The 4 communes were randomized to either an intervention condition or a standard care condition. The IDUs and their family members in the intervention condition completed 4 group sessions, with the aims to improve their mental health and family relations and to promote positive behavioral change. The intervention effect was evaluated at baseline and 3- and 6-month follow-up assessments. A significant reduction in depressive symptoms and improvement in family functioning were reported for IDUs in the intervention group compared with those in the standard care group. The family members in the intervention group reported better coping skills at 3 months, fewer depressive symptoms at 6 months, and improved family function at both 3 and 6 months compared with those in the standard care group. However, no significant intervention effect was observed for IDUs in terms of drug-using behavior. This study demonstrates the feasibility and preliminary outcomes of an intervention that simultaneously targets IDUs and their family members in Vietnam. Study findings highlight the importance of including family members and enhancing their role in drug use intervention efforts.

Mental health and family relations among people who inject drugs and their family members in Vietnam

BACKGROUND

This article explores the association of people who inject drugs and their family members in terms of mental health and family relations. The objective was to understand the family context and its impact on people who inject drugs in a family-oriented culture in Vietnam.

METHODS

Cross-sectional assessment data were gathered from 83 people who inject drugs and 83 of their family members recruited from four communes in Phú Thọ province, Vietnam. Depressive symptoms and family relations were measured for both people who inject drugs and family members. Internalized shame and drug-using behavior were reported by people who inject drugs, and caregiver burden was reported by family members.

RESULTS

We found that higher level of drug using behavior of people who inject drugs was significantly associated with higher depressive symptoms and lower family relations reported by themselves as well as their family members. Family relations reported by people who inject drugs and their family members were positively correlated.

CONCLUSION

The findings highlight the need for interventions that address psychological distress and the related challenges faced by family members of people who inject drugs. The article has policy implication which concludes with an argument for developing strategies that enhance the role of families in supporting behavioral change among people who inject drugs.

Effects of an HIV peer prevention intervention on sexual and injecting risk behaviors among injecting drug users and their risk partners in Thai Nguyen, Vietnam: a randomized controlled trial

Globally, 30% of new HIV infections outside sub-Saharan Africa involve injecting drug users (IDU) and in many countries, including Vietnam, HIV epidemics are concentrated among IDU. We conducted a randomized controlled trial in Thai Nguyen, Vietnam, to evaluate whether a peer oriented behavioral intervention could reduce injecting and sexual HIV risk behaviors among IDU and their network members. 419 HIV-negative index IDU aged 18 years or older and 516 injecting and sexual network members were enrolled. Each index participant was randomly assigned to receive a series of six small group peer educator-training sessions and three booster sessions in addition to HIV testing and counseling (HTC) (intervention; n = 210) or HTC only (control; n = 209). Follow-up, including HTC, was conducted at 3, 6, 9 and 12 months post-intervention. The proportion of unprotected sex dropped significantly from 49% to 27% (SE (difference) = 3%, p < 0.01) between baseline and the 3-month visit among all index-network member pairs. However, at 12 months, post-intervention, intervention participants had a 14% greater decline in unprotected sex relative to control participants (Wald test = 10.8, df = 4, p = 0.03). This intervention effect is explained by trial participants assigned to the control arm who missed at least one standardized HTC session during follow-up and subsequently reported increased unprotected sex. The proportion of observed needle/syringe sharing dropped significantly between baseline and the 3-month visit (14% vs. 3%, SE (difference) = 2%, p < 0.01) and persisted until 12 months, but there was no difference across trial arms (Wald test = 3.74, df = 3, p = 0.44).