HIV/AIDS epidemics in Vietnam: evolution and responses

Increase in human immunodeficiency virus and syphilis prevalence and incidence among men who have sex with men, vietnam 2015 - 2020

INTRODUCTION

We assessed trends in HIV and syphilis prevalence, HIV incidence, related risk factors, and preventive behaviors among men who have sex with men (MSM) in Vietnam from 2015 to 2020.

METHODS

Data originated from the HIV Sentinel Surveillance Plus system, which sampled MSM at venues and hotspots in seven of Vietnam's 63 provinces in 2015, 2016, 2018, and 2020 (N = 1100-1445 per year; ∼150-300 per province per year).

RESULTS

HIV prevalence estimates increased from 6.6% (95% CI 4.5-9.6) in 2015 to 13.8% (95% CI 10.5-18.2, p = .001 for trend) in 2020 overall, and separately in An Giang, Can Tho, Hai Phong, and Khanh Hoa provinces but not in Ho Chi Minh City, Hanoi, or Kien Giang. Syphilis prevalence increased from 2.7% (95% CI 1.4-5.1) in 2015 to 12.6% (95% CI 8.7-18.0) in 2020 overall (p < .001 for trend), and separately in An Giang, Can Tho, and Hai Phong provinces but not in Ho Chi Minh City or Kien Giang. We calculated time-at-risk from first anal sex to first HIV-positive or last HIV-negative test to estimate HIV incidence. Estimated HIV incidence suggested increasing rates of seroconversion from 1.36 per 100 person-years experienced by participants in 2015 to 2.61 per 100 person-years among participants in 2020 (hazard ratio per year 1.13, 95% CI 1.08-1.18, p < .001). There was a statistically significant increase in HIV testing, STI testing, and receipt of free condoms over the period (p < .05 for trend), and a statistically significant decrease in amphetamine use (p = .043 for trend).

CONCLUSIONS

Despite prevention efforts and improvements in some risk indicators, consecutive cross-sectional sampling results provide evidence of increasing incidence of HIV and syphilis among MSM in Vietnam, especially outside the major cities. Aggressive HIV prevention and treatment services can be expanded while conducting deeper investigations into the causes of these increases.

How has the COVID-19 epidemic affected the risk behaviors of people who inject drugs in a city with high harm reduction service coverage in Vietnam? A qualitative investigation

Introduction

The COVID-19 outbreak disproportionally affects vulnerable populations including people who inject drugs (PWID). Social distancing and stay-at-home orders might result in a lack of access to medical and social services, poorer mental health, and financial precariousness, and thus, increases in HIV and HCV risk behaviors. This article explores how the HIV/HCV risk behaviors of PWID in Haiphong, a city with high harm reduction service coverage in Vietnam, changed during the early phase of the COVID-19 pandemic, and what shaped such changes, using the risk environment framework.

Method

We conducted three focus group discussions with peer outreach workers in May 2020 at the very end of the first lockdown, and 30 in-depth interviews with PWID between September and October 2020, after the second wave of infection in Vietnam. Discussions and interviews centered on the impact of the COVID-19 pandemic on their lives, and how their drug use and sexual behaviors changed as a result of the pandemic.

Results

The national shutdown of nonessential businesses due to the COVID-19 epidemic caused substantial economic challenges to participants, who mostly were in a precarious financial situation before the start of the epidemic. Unsafe injection is no longer an issue among our sample of PWID in Haiphong thanks to a combination of different factors, including high awareness of injection-related HIV/HCV risk and the availability of methadone treatment. However, group methamphetamine use as a means to cope with the boredom and stress related to COVID-19 was common during the lockdown. Sharing of smoking equipment was a standard practice. Female sex workers, especially those who were active heroin users, suffered most from COVID-related financial pressure and may have engaged in unsafe sex.

Conclusion

While unsafe drug injection might no longer be an issue, group methamphetamine use and unsafe sex were the two most worrisome HIV/HCV risk behaviors of PWID in Haiphong during the social distancing and lockdown periods. These elevated risks could continue beyond the enforced lockdown periods, given PWID in general, and PWID who are also sex workers in particular, have been disproportionately affected during the global crisis.

Examining common mental health disorders in people living with HIV on methadone maintenance therapy in Hanoi, Vietnam

BACKGROUND

Injection drug use drives HIV transmission in Southeast Asia, where around a quarter of users are living with HIV. Vietnam developed Methadone Maintenance Therapy (MMT) programs to reduce unsafe drug abuse. Common mental health disorders (CMD), including depression, anxiety and post-traumatic stress disorder (PTSD), can worsen MMT outcomes and are highly prevalent among people living with HIV (PLH). We aimed to characterize HIV and CMD among MMT patients and assess the impact of HIV and CMD on MMT engagement outcomes in Hanoi, Vietnam.

METHODS

This cross-sectional study was conducted at an urban MMT clinic in Hanoi. Participants were screened for CMD with the relevant sections of the Mini International Neuropsychiatric Interview (MINI). Tabular comparisons and regression models were used to understand the association of HIV and CMD with substance use and methadone compliance.

RESULTS

Of the 400 MMT participants, 22% were living with HIV, 11% a CMD, 27% reported injection drug use, and 27% reported methadone noncompliance. Around 17% of those with HIV also had a CMD. Reporting non injection and injection drug use were each higher among those with CMD regardless of HIV status. In addition, reporting any drug use was much higher among those with both HIV and CMD than among those with neither (73% vs 31%, p value 0.001). While methadone noncompliance was lower among PLH than among those without HIV (16.3% vs 30.1%, p value 0.010), noncompliance was higher among those with CMD than among those without (40.5% vs 25.6%, p value 0.045). Among those without HIV, noncompliance was higher among those with CMD than among those without, but among those with HIV, the opposite relationship was observed.

CONCLUSION

There is complex overlap between substance use and methadone noncompliance among MMT patients living with HIV, CMD or both. In this population, we found a high prevalence of CMD and substance use among PLH, and a high prevalence of substance use and methadone noncompliance among those with CMD. Prioritizing provision of mental health care services to MMT patients living with HIV can help improve engagement with substance use disorder treatment and reduce the risk of HIV transmission.

HIV- and Drug Use-Related Stigma and Service Provision Among Community Health Workers in Vietnam

This study compared community health workers' (CHW) stigma towards people living with HIV (PLH) and people who use drugs (PWUD) and explored the relationship between stigma and CHWs' confidence level in providing HIV/drug-related services. Using two sets of identically worded questions, levels of stigma towards PWUD and PLH were measured among 120 CHW from 60 communes in Vietnam. The associations between CHWs' confidence in service provision and stigma towards PWUD and PLH were examined using a linear mixed-effects regression model. The majority of the CHW reported higher levels of stigma towards PWUD than towards PLH. Compared to the CHW reporting higher stigma towards PWUD, those with higher stigma towards PLH were significantly less confident in service provision. Social opprobrium attached to drug-using behaviors can be a major driver behind the overall HIV stigma. CHWs' fear of HIV infection should be tackled to boost their confidence in HIV/drug-related care provision.

Lack of Knowledge about Sexually Transmitted Diseases (STDs): Implications for STDs Prevention and Care among Dermatology Patients in an Urban City in Vietnam

Sexually transmitted diseases (STDs) are a substantial global burden of diseases, especially in developing countries. Lack of awareness of STDs may lead to a delay in treatment. This study aimed to assess knowledge about STDs and the associated factors among dermatological patients. A cross-sectional study was conducted among 622 patients at Vietnam National Hospital of Dermatology and Venereology (NHD). Structured questionnaires were used to investigate the knowledge about STDs. A multivariate Tobit regression was employed to determine factors associated with knowledge about STDs. The percentage of patients knowing that syphilis was an STD was highest (57.8%), followed by herpes warts (57.7%) and HIV/AIDS (57.4%). By contrast, 26.6% and 17.2% of patients knew that chlamydia and hepatitis C were STDs. The most commonly stated symptom of STDs was purulent genital (53.5%). Nearly two-thirds of participants were aware of the curability of STDs, and 34.7% knew about vaccines for STDs. Living with partners, young age, and acquired knowledge of STDs via the Internet, social networks, and health staff were positively related to having better knowledge about STDs. Based on the results of this study, peer education, informal conversations within clusters, mass community campaigns through the Internet and social networks, and the use of online health care providers should be promoted in order to improve awareness of STDs.

Study design and the estimation of the size of key populations at risk of HIV: lessons from Viet Nam

BACKGROUND

Estimation of the size of populations at risk of HIV is a key activity in the surveillance of the HIV epidemic. The existing framework for considering future research needs may provide decision-makers with a basis for a fair process of deciding on the methods of the estimation of the size of key populations at risk of HIV. This study explores the extent to which stakeholders involved with population size estimation agree with this framework, and thus, the study updates the framework.

METHODS

We conducted 16 in-depth interviews with key informants from city and provincial governments, NGOs, research institutes, and the community of people at risk of HIV. Transcripts were analyzed and reviewed for significant statements pertaining to criteria. Variations and agreement around criteria were analyzed, and emerging criteria were validated against the existing framework.

RESULTS

Eleven themes emerged which are relevant to the estimation of the size of populations at risk of HIV in Viet Nam. Findings on missing criteria, inclusive participation, community perspectives and conflicting weight and direction of criteria provide insights for an improved framework for the prioritization of population size estimation methods.

CONCLUSIONS

The findings suggest that the exclusion of community members from decision-making on population size estimation methods in Viet Nam may affect the validity, use, and efficiency of the evidence generated. However, a wider group of decision-makers, including community members among others, may introduce diverse definitions, weight and direction of criteria. Although findings here may not apply to every country with a transitioning economy or to every emerging epidemic, the principles of fair decision-making, value of community participation in decision-making and the expected challenges faced, merit consideration in every situation.

Increased Survival Among HIV-Infected PWID Receiving a Multi-Level HIV Risk and Stigma Reduction Intervention: Results From a Randomized Controlled Trial

OBJECTIVE

In Vietnam, where 58% of prevalent HIV cases are attributed to people who inject drugs, we evaluated whether a multi-level intervention could improve care outcomes and increase survival.

METHODS

We enrolled 455 HIV-infected males who inject drugs from 32 communes in Thai Nguyen Province. Communes were randomized to a community stigma reduction intervention or standard of care and then within each commune, to an individual enhanced counseling intervention or standard of care, resulting into 4 arms: Arm 1 (standard of care); Arm 2 (community intervention alone); Arm 3 (individual intervention alone); and Arm 4 (community + individual interventions). Follow-up was conducted at 6, 12, 18, and 24 months to assess survival.

RESULTS

Overall mortality was 23% (n = 103/455) more than 2 years. There were no losses to follow-up for the mortality endpoint. Survival at 24 months was different across arms: Arm 4 (87%) vs Arm 1 (82%) vs Arm 2 (68%) vs Arm 3 (73%); log-rank test for comparison among arms: P = 0.001. Among those with CD4 cell count <200 cells/mm and not on antiretroviral therapy at baseline (n = 162), survival at 24 months was higher in Arm 4 (84%) compared with other arms (Arm 1: 61%; Arm 2: 50%; Arm 3: 53%; P-value = 0.002). Overall, Arm 4 (community + individual interventions) had increased uptake of antiretroviral therapy compared with Arms 1, 2, and 3.

CONCLUSIONS

This multi-level behavioral intervention seemed to increase survival of HIV-infected participants more than a 2-year period. Relative to the standard of care, the greatest intervention effect was among those with lower CD4 cell counts.

"Social Crimes": Understandings of HIV/AIDS as a Disease Among Grandparents Raising Grandchildren in Vietnam

Grandparent caregivers are vital to the survival of grandchildren who are orphaned and who have been affected by HIV/AIDS. The purpose of this qualitative study was to understand the meaning of HIV as a disease among grandparents raising grandchildren orphaned by HIV/AIDS in northern Vietnam and to gain insight into how this understanding affected grandparents' relationships and health-seeking decisions. Results indicated that grandparents had knowledge deficits about the biomedical aspects of the disease and often hid their grandchildren's HIV status or preferred not to seek testing. Effective interventions must address stigma reduction, family relationships, and access to health care to increase testing and treatment of grandchildren.

Demographic and behavioral correlates of HIV/STI among Vietnamese female sex workers in southwest China

Previous literature has suggested high rates of HIV/STIs among Chinese FSWs. However, limited data were available regarding HIV-related risks among Vietnamese FSWs - a rapidly increasing, vulnerable population in southwest China. The current study examined the demographic and behavioral factors associated with the infection rates of HIV, syphilis, and Hepatitis C (HCV) among Vietnamese FSWs in Guangxi, China. We conducted a secondary data analysis of a cumulative sample of 1026 Vietnamese FSWs (aged 14-66) recruited over five years (2010-2014) from 35 National Sentinel Surveillance sites in Guangxi. Analyses included Fisher's exact chi-square test, t-test, and binary logistic regression. The overall prevalence of HIV, syphilis, and HCV infections among the cross-border women were 3.2%, 6.9%, and 2.6%, respectively. Multivariate analysis showed that greater lengths of sex work and low paying work venues were significant risk factors for HIV infection; for syphilis infection, older age, drug use experience, and forgoing condom use were significant risk factors; for HCV infection, drug use experience was the only significant risk factor. Our findings suggest that elevated HIV-related risks among the Vietnamese FSWs are closely related to their financial disadvantages and that drug use is a prominent risk factor for cross-border women in the sex trade. Furthermore, culturally tailored and linguistically accessible HIV prevention and intervention initiatives that target cross-border FSWs, with a close international collaboration between China and Vietnam, are urgently needed.

Tuberculosis and HIV co-infection in Vietnam

Tuberculosis (TB) and human immunodeficiency virus (HIV) infection are leading causes of disease and death in Vietnam, but TB/HIV disease trends and the profile of co-infected patients are poorly described.

METHODS

We examined national TB and HIV notification data to provide a geographic overview and describe relevant disease trends within Vietnam. We also compared the demographic and clinical profiles of TB patients with and without HIV infection.

RESULTS

During the past 10 years (2005-2014) cumulative HIV case numbers and deaths increased to 298,151 and 71,332 respectively, but access to antiretroviral therapy (ART) improved and new infections and deaths declined. From 2011-2014 routine HIV testing of TB patients increased from 58.9% to 72.5% and of all TB patients diagnosed with HIV in 2014, 2,803 (72.4%) received ART. The number of multidrug resistant (MDR)-TB cases enrolled for treatment increased almost 3-fold (578 to 1,532) from 2011-2014. The rate of HIV co-infection in MDR and non-MDR TB cases (51/1,532; 3.3% vs 3,774/100,555; 3.8%; OR 0.77, 95% CI 0.7-1.2) was similar in 2014.

CONCLUSIONS

The care of TB/HIV co-infected patients have shown sustained improvement in Vietnam. Rising numbers of MDR-TB cases is a concern, but this is not "driven" by HIV co-infection.

Projecting the epidemiological effect, cost-effectiveness and transmission of HIV drug resistance in Vietnam associated with viral load monitoring strategies

OBJECTIVES

The objective of this study was to investigate the potential epidemiological impact of viral load (VL) monitoring and its cost-effectiveness in Vietnam, where transmitted HIV drug resistance (TDR) prevalence has increased from <5% to 5%-15% in the past decade.

METHODS

Using a population-based mathematical model driven by data from Vietnam, we simulated scenarios of various combinations of VL testing coverage, VL thresholds for second-line ART initiation and availability of HIV drug-resistance tests. We assessed the cost per disability-adjusted life year (DALY) averted for each scenario.

RESULTS

Projecting expected ART scale-up levels, to approximately double the number of people on ART by 2030, will lead to an estimated 18 510 cases (95% CI: 9120-34 600 cases) of TDR and 55 180 cases (95% CI: 40 540-65 900 cases) of acquired drug resistance (ADR) in the absence of VL monitoring. This projection corresponds to a TDR prevalence of 16% (95% CI: 11%-24%) and ADR of 18% (95% CI: 15%-20%). Annual or biennial VL monitoring with 30% coverage is expected to relieve 12%-31% of TDR (2260-5860 cases), 25%-59% of ADR (9620-22 650 cases), 2%-6% of HIV-related deaths (360-880 cases) and 19 270-51 400 DALYs during 2015-30. The 30% coverage of VL monitoring is estimated to cost US$4848-5154 per DALY averted. The projected additional cost for implementing this strategy is US$105-268 million over 2015-30.

CONCLUSIONS

Our study suggests that a programmatically achievable 30% coverage of VL monitoring can have considerable benefits for individuals and leads to population health benefits by reducing the overall national burden of HIV drug resistance. It is marginally cost-effective according to common willingness-to-pay thresholds.

Estimating the Cost-Effectiveness of HIV Prevention Programmes in Vietnam, 2006-2010: A Modelling Study

Introduction

Vietnam has been largely reliant on international support in its HIV response. Over 2006-2010, a total of US$480 million was invested in its HIV programmes, more than 70% of which came from international sources. This study investigates the potential epidemiological impacts of these programmes and their cost-effectiveness.

Methods

We conducted a data synthesis of HIV programming, spending, epidemiological, and clinical outcomes. Counterfactual scenarios were defined based on assumed programme coverage and behaviours had the programmes not been implemented. An epidemiological model, calibrated to reflect the actual epidemiological trends, was used to estimate plausible ranges of programme impacts. The model was then used to estimate the costs per averted infection, death, and disability adjusted life-year (DALY).

Results

Based on observed prevalence reductions amongst most population groups, and plausible counterfactuals, modelling suggested that antiretroviral therapy (ART) and prevention programmes over 2006-2010 have averted an estimated 50,600 [95% uncertainty bound: 36,300–68,900] new infections and 42,600 [36,100–54,100] deaths, resulting in 401,600 [312,200–496,300] fewer DALYs across all population groups. HIV programmes in Vietnam have cost an estimated US$1,972 [1,447–2,747], US$2,344 [1,843–2,765], and US$248 [201–319] for each averted infection, death, and DALY, respectively.

Conclusions

Our evaluation suggests that HIV programmes in Vietnam have most likely had benefits that are cost-effective. ART and direct HIV prevention were the most cost-effective interventions in reducing HIV disease burden.

Efficacy of a Multi-level Intervention to Reduce Injecting and Sexual Risk Behaviors among HIV-Infected People Who Inject Drugs in Vietnam: A Four-Arm Randomized Controlled Trial

Introduction

Injecting drug use is a primary driver of HIV epidemics in many countries. People who inject drugs (PWID) and are HIV infected are often doubly stigmatized and many encounter difficulties reducing risk behaviors. Prevention interventions for HIV-infected PWID that provide enhanced support at the individual, family, and community level to facilitate risk-reduction are needed.

Methods

455 HIV-infected PWID and 355 of their HIV negative injecting network members living in 32 sub-districts in Thai Nguyen Province were enrolled. We conducted a two-stage randomization: First, sub-districts were randomized to either a community video screening and house-to-house visits or standard of care educational pamphlets. Second, within each sub-district, participants were randomized to receive either enhanced individual level post-test counseling and group support sessions or standard of care HIV testing and counseling. This resulted in four arms: 1) standard of care; 2) community level intervention; 3) individual level intervention; and 4) community plus individual intervention. Follow-up was conducted at 6, 12, 18, and 24 months. Primary outcomes were self-reported HIV injecting and sexual risk behaviors. Secondary outcomes included HIV incidence among HIV negative network members.

Results

Fewer participants reported sharing injecting equipment and unprotected sex from baseline to 24 months in all arms (77% to 4% and 24% to 5% respectively). There were no significant differences at the 24-month visit among the 4 arms (Wald = 3.40 (3 df); p = 0.33; Wald = 6.73 (3 df); p = 0.08). There were a total of 4 HIV seroconversions over 24 months with no significant difference between intervention and control arms.

Discussion

Understanding the mechanisms through which all arms, particularly the control arm, demonstrated both low risk behaviors and low HIV incidence has important implications for policy and prevention programming.

Trial Registration

ClinicalTrials.gov NCT01689545

Expenditure Analysis of HIV Testing and Counseling Services Using the Cascade Framework in Vietnam

Objectives

Currently, HIV testing and counseling (HTC) services in Vietnam are primarily funded by international sources. However, international funders are now planning to withdraw their support and the Government of Vietnam (GVN) is seeking to identify domestic funding and generate client fees to continue services. A clear understanding of the cost to sustain current HTC services is becoming increasingly important to facilitate planning that can lead to making HTC and other HIV services more affordable and sustainable in Vietnam. The objectives of this analysis were to provide a snapshot of current program costs to achieve key program outcomes including 1) testing and identifying PLHIV unaware of their HIV status and 2) successfully enrolling HIV (+) clients in care.

Methods

We reviewed expenditure data reported by 34 HTC sites in nine Vietnamese provinces over a one-year period from October 2012 to September 2013. Data on program outcomes were extracted from the HTC database of 42,390 client records. Analysis was carried out from the service providers’ perspective.

Results

The mean expenditure for a single client provided HTC services (testing, receiving results and referral for care/treatment) was US $7.6. The unit expenditure per PLHIV identified through these services varied widely from US $22.8 to $741.5 (median: $131.8). Excluding repeat tests, the range for expenditure to newly diagnose a PLHIV was even wider (from US $30.8 to $1483.0). The mean expenditure for one successfully referred HIV client to care services was US $466.6. Personnel costs contributed most to the total cost.

Conclusions

Our analysis found a wide range of expenditures by site for achieving the same outcomes. Re-designing systems to provide services at the lowest feasible cost is essential to making HIV services more affordable and treatment for prevention programs feasible in Vietnam. The analysis also found that understanding the determinants and reasons for variance in service costs by site is an important enhancement to the cascade of HIV services framework now adapted for and extensively used in Vietnam for planning and evaluation.

High proportion of HIV serodiscordance among HIV-affected married couples in northern Vietnam

INTRODUCTION

Little is known about the state of HIV transmission among married couples in Vietnam. This study aims to clarify HIV serostatus in this group and elucidate risk factors for intra-marital HIV transmission.

METHODS

In 2012, we enrolled a group of HIV-positive married men registered at the HIV outpatient clinic of a referral hospital in northern Vietnam, along with their wives. Sociodemographic, behavioural and clinical data were collected from men and wives. HIV serodiscordant couples were followed until March 2014 to determine seroconversion rate. A phylogenetic analysis was performed based on env V3 sequence to detail cluster formation among men.

RESULTS

Of the 163 HIV-positive men enrolled in the study, 101 (62.0%) had wives testing HIV-negative. Half of men reported injecting drug use (IDU) as a likely transmission route. Couples reported a high incidence of unprotected sexual intercourse prior to diagnosis; the median (inter quartile range) was 4 (4-8) times per month. Only 17 couples (10.4%) reported using condoms during at least half these instances. Multivariable analysis revealed IDU history among men was independently associated with HIV-negative wives (adjusted OR 0.31; 95% CI 0.10-0.95, p=0.041). Phylogenetic analysis of 80 samples indicated CRF01_AE. Of these, 69 (86.3%) clustered with IDU-associated viruses from Vietnam. No HIV seroconversion was identified during a follow-up of 61 serodiscordant couples, with 126.5 person-years of observation during which HIV-infected men were on antiretroviral drug therapy (ART).

CONCLUSION

High HIV serodiscordance was observed among HIV-affected married couples in northern Vietnam. A large number of at-risk wives therefore remain HIV-negative and can be protected with measures including proper use of ART if couples are made aware of the serodiscordance through screening.

Caught in the middle: the contested politics of HIV/AIDS and health policy in Vietnam

Drawing on the changing landscape of responses to HIV in Vietnam, this article describes the key players and analyzes the relationships between global players and local interests, including both the omnipresent state and an emerging civil society presence. We discuss the critical importance of timing for policy intervention and the role of health policy in shaping the broader social terrain. The interventions of external actors such as the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund were instrumental in improving both policies and programs at a critical juncture, when the national responses to the epidemic had been ineffective. At the same time, those global interventions met resistance and led to unintended consequences, both welcome and unwelcome. Furthermore, the looming specter of donor withdrawal and the very gradually emerging national ownership raise many questions about capacity for scale-up and sustainability of the significant achievements to date. Further monitoring and in-depth analysis of the Vietnamese responses to the HIV epidemic in the next few years or so, we contend, have the potential to provide unique insights into the challenges faced by developing countries caught in the complex webs of health politics and policies at both the global and the national levels.

Drug injecting and HIV risk among injecting drug users in Hai Phong, Vietnam: a qualitative analysis

BACKGROUND

Hai Phong, located in northern Vietnam, has become a high HIV prevalence province among Injecting Drug Users (IDUs) since the infection shifted from the southern to the northern region of the country. Previous research indicates high levels of drug and sex related risk behaviour especially among younger IDUs. Our recent qualitative research provides a deeper understanding of HIV risk behaviour and highlights views and experiences of IDUs relating to drug injecting and sharing practices.

METHODS

Fifteen IDUs participated in semi-structured interviews conducted in September-October, 2012. Eligible participants were selected from those recruited in a larger scale behavioural research project and identified through screening questions. Interviews were conducted by two local interviewers in Vietnamese and were audiotaped. Ethical procedures, including informed consent and participants' understanding of their right to skip and withdraw, were applied. Transcripts were translated and double checked. The data were categorised and coded according to themes. Thematic analysis was conducted and a qualitative data analysis thematic framework was used.

RESULTS

Qualitative analysis highlighted situational circumstances associated with HIV risks among IDUs in Hai Phong and revealed three primary themes: (i) places for injecting, (ii) injecting drugs in small groups, and (iii) sharing practices. Our results showed that shared use of jointly purchased drugs and group injecting were widespread among IDUs without adequate recognition of these as HIV risk behaviours. Frequent police raids generated a constant fear of arrest. As a consequence, the majority preferred either rail lines or isolated public places for injection, while some injected in their own or a friend's home. Price, a heroin crisis, and strong group norms encouraged collective preparation and group injecting. Risk practices were enhanced by a number of factors: the difficulty in getting new syringes, quick withdrawal management, punitive attitudes, fear of arrest/imprisonment, lack of resources, incorrect self-assessment, and risk denial. Some of the IDU participants emphasised self-care attitudes which should be encouraged to minimise HIV transmission risk.

CONCLUSION

The IDUs' experiences in Hai Phong identified through our data broaden our qualitative understanding about the HIV transmission risk among IDUs and emphasize the need to strengthen harm reduction services in Vietnam.

Sexual practices, partner concurrency and high rates of sexually transmissible infections among male sex workers in three cities in Vietnam

Background This paper examines sexual practices, partner concurrency and sexually transmissible infections (STI)/HIV infection among male sex workers (MSWs) in Vietnam.

METHODS

Six hundred and fifty-four MSWs, aged 16-35 years, were recruited in Hanoi, Nha Trang and Ho Chi Minh City between 2009 and 2011. Survey measures included demographic characteristics, drug use, types of sexual partners and sexual practices. Subjects were screened for STIs, including HIV.

RESULTS

MSWs in Ho Chi Minh City (33%) were more likely than those from the other two sites to be current users of one or more types of illegal drugs (P<0.001). MSWs with both male and female elective partners (compared with other partnership types) were more likely to have anal sex with male client partners (P<0.001), elective male partners (P=0.045) and elective female partners (P=0.025). At last sex with a male client partner, only 30% used a condom during anal intercourse. At last sex with an elective female partner, only 31% used a condom during vaginal sex and only 3% during anal sex. Although rates of HIV are low (4%), other STIs are high, including chlamydia (17%), gonorrhoea (29%) and human papillomavirus (33%). Most (57.3%) have never been tested for HIV and only 17% have ever disclosed to a healthcare provider that they have sex with men.

CONCLUSIONS

Complex patterns of sexual concurrency, coupled with high rates of STIs, signal the urgent need for health services interventions among MSWs, both to improve individual health outcomes and to reduce secondary STI/HIV transmission among sexual partner networks.

Systematic review and meta-analysis of HIV prevalence among men in militaries in low income and middle income countries

OBJECTIVES

To determine whether the current HIV prevalence in militaries of low-income and middle-income countries is higher, the same, or lower than the HIV prevalence in the adult male population of those countries.

METHODS

HIV prevalence data from low-income and middle-income countries' military men were systematically reviewed during 2000-2012 from peer reviewed journals, clearing-house databases and the internet. Standardised data abstraction forms were used to collect information on HIV prevalence, military branch and sample size. Random effects meta-analyses were completed with the Mantel-Haenszel method comparing HIV prevalence among military populations with other men in each country.

RESULTS

2214 studies were retrieved, of which 18 studies representing nearly 150000 military men across 11 countries and 4 regions were included. Military male HIV prevalence across the studies ranged from 0.06% (n=22666) in India to 13.8% (n=2733) in Tanzania with a pooled prevalence of 1.1% (n=147591). HIV prevalence in male military populations in sub-Saharan Africa was significantly higher when compared with reproductive age (15-49 years) adult men (OR: 2.8, 95% CI 1.01 to 7.81). HIV prevalence in longer-serving male military populations compared with reproductive age adult men was significantly higher (OR: 2.68, 95% CI 1.65 to 4.35).

CONCLUSIONS

Our data reveals that across the different settings, the burden of HIV among militaries may be higher or lower than the civilian male populations. In this study, male military populations in sub-Saharan Africa, low-income countries and longer-serving men have significantly higher HIV prevalence. Given the national security implications of the increased burden of HIV, interventions targeting military personnel in these populations should be scaled up where appropriate.

Community-level income inequality and HIV prevalence among persons who inject drugs in Thai Nguyen, Vietnam

Socioeconomic status has a robust positive relationship with several health outcomes at the individual and population levels, but in the case of HIV prevalence, income inequality may be a better predictor than absolute level of income. Most studies showing a relationship between income inequality and HIV have used entire countries as the unit of analysis. In this study, we examine the association between income inequality at the community level and HIV prevalence in a sample of persons who inject drugs (PWID) in a concentrated epidemic setting. We recruited PWID and non-PWID community participants in Thai Nguyen, Vietnam, and administered a cross-sectional questionnaire; PWID were tested for HIV. We used ecologic regression to model HIV burden in our PWID study population on GINI indices of inequality calculated from total reported incomes of non-PWID community members in each commune. We also modeled HIV burden on interaction terms between GINI index and median commune income, and finally used a multi-level model to control for community level inequality and individual level income. HIV burden among PWID was significantly correlated with the commune GINI coefficient (r = 0.53, p = 0.002). HIV burden was also associated with GINI coefficient (β = 0.082, p = 0.008) and with median commune income (β = −0.018, p = 0.023) in ecological regression. In the multi-level model, higher GINI coefficient at the community level was associated with higher odds of individual HIV infection in PWID (OR = 1.46 per 0.01, p = 0.003) while higher personal income was associated with reduced odds of infection (OR = 0.98 per $10, p = 0.022). This study demonstrates a context where income inequality is associated with HIV prevalence at the community level in a concentrated epidemic. It further suggests that community level socioeconomic factors, both contextual and compositional, could be indirect determinants of HIV infection in PWID.

Vietnamese women's struggle to access antiretroviral drugs in a context of free treatment

This qualitative study aims to explore how HIV positive women living in a northern province of Vietnam experience seeking antiretroviral (ARV) treatment in the public health system, and how they address obstacles encountered along the way. Despite the fact that antiretroviral drugs were freely provided, they were not always accessible for women in need. A variety of factors at the population and health system level interacted in ways that often made access to ARV drugs a complicated and time-consuming process. We have suggested changes that could be made at the health system level that may help facilitate women's ability to access treatment.

Persisting stigma reduces the utilisation of HIV-related care and support services in Viet Nam

BACKGROUND

Seeking and utilisation of HIV prevention, treatment, care, and support services for people living with HIV is often hampered by HIV-related stigma. The study aimed to explore the perceptions and experiences regarding treatment, care, and support amongst people living with HIV in Viet Nam, where the HIV epidemic is concentrated among injecting drug users, sex workers, and men who have sex with men.

METHODS

In-depth interviews and focus group discussions were conducted during September 2007 in 6 districts in Hai Phong with a very high HIV prevalence among injecting drug users. The information obtained was analysed and merged within topic areas. Illustrative quotes were selected.

RESULTS

Stigma and discrimination against people living with HIV in the community and healthcare settings was commonly reported, and substantially hampered the seeking and the utilisation of HIV-related services. The informants related the high level of stigma to the way the national HIV preventive campaigns played on fear, by employing a "scare tactic" mainly focusing on drug users and sex workers, who were defined as "social evils" in the anti-drug and anti-prostitution policy. There was a strong exclusion effect caused by the stigma, with serious implications, such as loss of job opportunities and isolation. The support and care provided by family members was experienced as vital for the spirit and hope for the future among people living with HIV.

CONCLUSIONS

A comprehensive care and support programme is needed. The very high levels of stigma experienced seem largely to have been created by an HIV preventive scare tactic closely linked to the "social evil" approach in the national policy on drug and prostitution. In order to reduce the stigma and create more effective interventions, this tactic will have to be replaced with approaches that create better legal and policy environments for drug users and sex workers.

HIV/AIDS-Related Knowledge and Behaviors Among Most-at-Risk Populations in Vietnam

The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has supported the Vietnamese Ministry of Health (MOH) in implementing behavior change strategies to slow the HIV epidemic. These programs target commercial sex workers (CSW), injection drug users (IDU), and men who have sex with men (MSM). Using data from a program evaluation to assess effectiveness of the PEPFAR intervention, we conducted a sub-analysis of HIV/AIDS knowledge, sexual behaviors, and injection drug risk behaviors among 2,199 Vietnamese respondents, including those reporting recent contact with an outreach worker and those who did not report contact. We found overall high levels of HIV/AIDS knowledge, low rates of needle sharing, and moderate to high rates of inconsistent condom use. Average knowledge scores of IDU were significantly higher than non-IDU for antiretroviral treatment knowledge, while MSM had significantly less knowledge of treatment compared to non-MSM. HIV/AIDS-related knowledge was not significantly associated with needle-sharing practices. Knowledge was modestly but significantly associated with more consistent use of condoms with primary and commercial sex partners, even after controlling for contact with an outreach worker. Contact with an outreach worker was also an independent predictor of more consistent condom use. Outreach programs appear to play a meaningful role in changing sexual behavior, though the effect of outreach on IDU risk behaviors was less clear. More research is needed to understand the relationship between outreach programs and skill development, motivation, and use of referral services by most-at-risk populations in Vietnam.

Short communication: phylogenetic characterization of HIV type 1 CRF01_AE V3 envelope sequences in pregnant women in Northern Vietnam

Characterization of HIV-1 strains is important for surveillance of the HIV-1 epidemic. In Vietnam HIV-1-infected pregnant women often fail to receive the care they are entitled to. Here, we analyzed phylogenetically HIV-1 env sequences from 37 HIV-1-infected pregnant women from Ha Noi (n=22) and Hai Phong (n=15), where they delivered in 2005-2007. All carried CRF01_AE in the gp120 V3 region. In 21 women CRF01_AE was also found in the reverse transcriptase gene. We compared their env gp120 V3 sequences phylogenetically in a maximum likelihood tree to those of 198 other CRF01_AE sequences in Vietnam and 229 from neighboring countries, predominantly Thailand, from the HIV-1 database. Altogether 464 sequences were analyzed. All but one of the maternal sequences colocalized with sequences from northern Vietnam. The maternal sequences had evolved the least when compared to sequences collected in Ha Noi in 2002, as shown by analysis of synonymous and nonsynonymous changes, than to other Vietnamese sequences collected earlier and/or elsewhere. Since the HIV-1 epidemic in women in Vietnam may still be underestimated, characterization of HIV-1 in pregnant women is important to observe how HIV-1 has evolved and follow its molecular epidemiology.

The Cost of Providing HIV/AIDS Counseling and Testing Services in Vietnam

OBJECTIVE

This article aimed to provide estimates and analyses of the cost of providing voluntary counseling and testing (VCT) services for HIV/AIDS in a province in northern Vietnam.

METHODS

This facility-based costing study was conducted in the Thai Nguyen province, located 85 km north of Hanoi. Cost data were collected in six facility-based VCT units and two freestanding ones by using an ingredient approach. Both financial and economic costs of VCT services for HIV/AIDS were estimated from the perspective of the service providers.

RESULTS

The mean total annual financial costs of a facility-based and a freestanding VCT unit in the study site were US $15,673 and US $42,237, respectively. The mean total annual economic costs of these services were US $16,695 and US $44,682, respectively. The cost per visit to the facility-based VCT unit was lower than in the freestanding facility (financial cost of US $28.4 vs. US $36.8; economic cost of US $30.3 vs. US $38.9). The same was true for the cost per complete VCT procedure (financial cost of US $34.7 vs. US $38.0; economic cost of US $36.9 vs. US $40.2). The cost per HIV positive case detected in facility-based VCT unit was higher than that of the freestanding VCT unit (financial cost of US $149.3 vs. US $111.2; economic cost of US $159.0 vs. US $117.6).

CONCLUSIONS

The results of the present study offer preliminary evidence on economic aspects of providing VCT services in Vietnam. The findings from this study can serve as a basis for further studies as well as for program and policy development.

The effect of participatory community communication on HIV preventive behaviors among ethnic minority youth in central Vietnam

Background

In Vietnam, socially marginalized groups such as ethnic minorities in mountainous areas are often difficult to engage in HIV research and prevention programs. This intervention study aimed to estimate the effect of participatory community communication (PCC) on changing HIV preventive ideation and behavior among ethnic minority youth in a rural district from central Vietnam.

Methods

In a cross-sectional survey after the PCC intervention, using a structured questionnaire, 800 ethnic minority youth were approached for face-to-face interviews. Propensity score matching (PSM) technique was then utilized to match these participants into two groups-intervention and control-for estimating the effect of the PCC.

Results

HIV preventive knowledge and ideation tended to increase as the level of recall changed accordingly. The campaign had a significant indirect effect on condom use through its effect on ideation or perceptions. When intervention and control group statistically equivalently reached in terms of individual and social characteristics by PSM, proportions of displaying HIV preventive knowledge, ideation and condom use were significantly higher in intervention group than in matched control counterparts, accounting for net differences of 7.4%, 12.7% and 5%, respectively, and can be translated into the number of 210; 361 and 142 ethnic minority youth in the population.

Conclusions

The study informs public health implications both theoretically and practically to guide effective HIV control programs for marginalized communities in resources-constrained settings like rural Vietnam and similar contexts of developing countries.

Accelerated transition to injection among male heroin initiates in Hanoi, Vietnam: implications for early harm reduction interventions

This paper examines changes in the interval between first heroin smoking and onset of injection in a large, out-treatment sample of male heroin users in Hanoi, Vietnam (n = 1,115). Mean age at initiation of heroin use (smoking) was 18.4 and mean age of onset of heroin injection was 20.9 years. Full multivariate analysis indicates that the interval between first heroin use (smoking) and first heroin injection has been significantly attenuated among more recent heroin initiates (P = 0.0043), suggesting that heroin users in Vietnam may be at increased risk for exposure to HIV relatively soon after onset of heroin use, highlighting the need for behavioral interventions that target heroin smokers. Critical intervention goals include delaying the onset of injection and improved education about safer drug sharing and drug injection practices.

Gender, Alcohol Consumption Patterns, and Engagement in Sexually Intimate Behaviors Among Adolescents and Young Adults in Nha Trang, Viet Nam

A randomly selected cross-sectional survey was conducted with 880 youth (16 to 24 years) in Nha Trang City to assess relationships between alcohol consumption and sexual behaviors. A timeline followback method was employed. Chi-square, generalized logit modeling and logistic regression analyses were performed. Of the sample, 78.2% male and 56.1% female respondents ever consumed alcohol. Males reporting sexual behaviors (vaginal, anal, oral sex) had a significantly higher calculated peak BAC of 0.151 compared to 0.082 for males reporting no sexual intimacy (p < .0001). Females reporting sexual behaviors had a peak BAC of 0.072 compared to 0.027 for those reporting no sexual intimacy (p = .016). Fifty percent of (33/66) males and 30.4% (7/23) females report event specific drinking and engagement in sexual behaviors. Males reporting 11+ drinks in 30 days had more sexual partners than those reporting 1 to 10 drinks (p = .037). Data suggest different physical and psychosocial mediators between alcohol consumption and sexual behaviors by gender.

The evolution of HIV policy in Vietnam: from punitive control measures to a more rights-based approach

Aim

Policymaking in Vietnam has traditionally been the preserve of the political elite, not open to the scrutiny of those outside the Communist Party. This paper aims to analyse Vietnam's HIV policy development in order to describe and understand the policy content, policy-making processes, actors and obstacles to policy implementation.

Methods

Nine policy documents on HIV were analysed and 17 key informant interviews were conducted in Hanoi and Quang Ninh Province, based on a predesigned interview guide. Framework analysis, a type of qualitative content analysis, was applied for data analysis.

Results

Our main finding was that during the last two decades, developments in HIV policy in Vietnam were driven in a top-down way by the state organs, with support and resources coming from international agencies. Four major themes were identified: HIV policy content, the policy-making processes, the actors involved and human resources for policy implementation. Vietnam's HIV policy has evolved from one focused on punitive control measures to a more rights-based approach, encompassing harm reduction and payment of health insurance for medical costs of patients with HIV-related illness. Low salaries and staff reluctance to work with patients, many of whom are drug users and female sex workers, were described as the main barriers to low health staff motivation.

Conclusion

Health policy analysis approaches can be applied in a traditional one party state and can demonstrate how similar policy changes take place, as those found in pluralistic societies, but through more top-down and somewhat hidden processes. Enhanced participation of other actors, like civil society in the policy process, is likely to contribute to policy formulation and implementation that meets the diverse needs and concerns of its population.

Peer-Driven Interventions in Vietnam and China to Prevent HIV: A Pilot Study Targeting Injection Drug Users

The HIV epidemic in China and Vietnam is on the increase among injection drug users (IDUs). We report on the results of a pilot outreach study in northern Vietnam and southern China to test the feasibility of a peer-driven intervention (PDI) to prevent HIV among IDUs. In the PDI, recruitment relies on a “chain-referral” model in which IDUs carry-out the core outreach activities that salaried outreach-workers/peer-educators traditionally provide. A 6-month follow-up was built into the study design to measure possible changes in IDUs' risk behaviors. The impact results of the pilot study are reported bearing on several different measures, such as changes in IDUs' rates of lending or borrowing used syringes, willingness to enter into drug treatment, baseline and follow-up recruitment success, and effectiveness of serving as peer-educators in the community. The evidence suggests the PDI is highly feasible and deserving of greater research in both China and Vietnam.

Lack of knowledge about sexually transmitted infections among women in North rural Vietnam

BACKGROUND

The serious long-term complications of sexually transmitted infections (STI) in women and newborns are well-documented. Particularly, STI imply considerable social consequences for women. Low STI knowledge has been shown to be associated with unsafe sex. In Vietnam, misconceptions regarding STI exist, and rural women delay seeking care for STI. The aim of the study was to investigate knowledge of STI among women aged 15 to 49 years in a rural district of Vietnam and to evaluate possible associations between socioeconomic factors and STI knowledge.

METHODS

A cross-sectional population-based study using face-to-face interviews was carried out between March and May 2006 in a demographic surveillance site in rural Vietnam. In total, 1805 women aged 15-49 years were randomly selected to participate in the study. The interviews were based on a structured questionnaire including questions on sociodemographic characteristics of the women and their knowledge about STI. Each correct answer was scored 1, incorrect or do not know answer was scored 0. Multivariate analyses were applied to examine associations between socio-economic conditions and STI knowledge. Intra-cluster correlation was calculated to examine similarities of STI knowledge within clusters.

RESULTS

Of the 1,805 respondents, 78% (73% married vs. 93% unmarried, p < 0.001) did not know any symptoms of STI, 50% could not identify any cause of STI, 59% (54% married vs. 76% unmarried, p < 0.001) did not know that STI can be prevented. Only 31% of the respondents (36% married vs. 14% unmarried, p < 0.001) answered that condom use could protect against STI, and 56% considered partner treatment necessary. Of 40 possible correct answers, the mean knowledge score was 6.5 (range 0-26, median 6). Young, unmarried women and women who lived in the highlands or mountainous areas demonstrated very low levels of STI knowledge (regression coefficients -1.3 and -2.5, respectively, p < 0.001). Experience of an induced abortion was significantly associated with a higher level of knowledge.

CONCLUSION

The low levels of STI knowledge found among women of reproductive age in a rural district of Vietnam indicate an urgent need of health education interventions, of which, young and unmarried women should be specifically targeted.

Risks for HIV, HBV, and HCV infections among male injection drug users in northern Vietnam: a case-control study

Injection drug use (IDU) and HIV infection are important public health problems in Vietnam. The IDU population increased 70% from 2000 to 2004 and is disproportionately affected by HIV and AIDS -- the country's second leading cause of death. Hepatitis B virus (HBV) and hepatitis C virus (HCV) share transmission routes with HIV and cause serious medical consequences. This study aimed to determine risk factors for acquisition of HIV, HBV, and HCV infections among IDUs in a northern province. We conducted a matched case-control study among active IDUs aged 18-45 who participated in a community-based survey (30-minute interview and serologic testing). Each HIV-infected IDU (case) was matched with one HIV-uninfected IDU (control) by age, sex (males only), and study site (128 pairs). Similar procedures were used for HBV infection (50 pairs) and HCV infection (65 pairs). Conditional logistic regression models were fit to identify risk factors for each infection. Among 309 surveyed IDUs, the HIV, HBV, and HCV prevalence was 42.4%, 80.9%, and 74.1%, respectively. Only 11.0% reported having been vaccinated against hepatitis B. While 13.3% of the IDUs reported sharing needles (past six months), 63.8% engaged in indirect sharing practices (past six months), including sharing drug solutions, containers, rinse water, and frontloading drugs. In multivariable models, sharing drugs through frontloading was significantly associated with HIV infection (odds ratio [OR]=2.8), HBV infection (OR=3.8), and HCV infection (OR=4.6). We report an unrecognized association between sharing drugs through frontloading and higher rates of HIV, HBV and HCV infections among male IDUs in Vietnam. This finding may have important implications for bloodborne viral prevention for IDUs in Vietnam.

The context of HIV risk behaviours among HIV-positive injection drug users in Viet Nam: moving toward effective harm reduction

Background

Injection drug users represent the largest proportion of all HIV reported cases in Viet Nam. This study aimed to explore the perceptions of risk and risk behaviours among HIV-positive injection drug users, and their experiences related to safe injection and safe sex practices.

Methods

This study used multiple qualitative methods in data collection including in-depth interviews, focus group discussions and participant observation with HIV-positive injection drug users.

Results

The informants described a change in the sharing practices among injection drug users towards more precautions and what was considered 'low risk sharing', like sharing among seroconcordant partners and borrowing rather than lending. However risky practices like re-use of injection equipment and 'syringe pulling' i.e. the use of left-over drugs in particular, were frequently described and observed. Needle and syringe distribution programmes were in place but carrying needles and syringes and particularly drugs could result in being arrested and fined. Fear of rejection and of loss of intimacy made disclosure difficult and was perceived as a major obstacle for condom use among recently diagnosed HIV infected individuals.

Conclusion

HIV-positive injection drug users continue to practice HIV risk behaviours. The anti-drug law and the police crack-down policy appeared as critical factors hampering ongoing prevention efforts with needle and syringe distribution programmes in Viet Nam. Drastic policy measures are needed to reduce the very high HIV prevalence among injection drug users.

Household survey in two provinces in Viet Nam estimates HIV prevalence in an urban and a rural population

A household-based population study interviewed 2,553 women and 1,984 men aged 15-49 years in urban (Ho Chi Minh City) and rural (Thai Binh) provinces in Viet Nam between July and August 2005. The survey response rate was high--approximately 97% of households and 93% of adults overall, with a >92% acceptance of HIV testing among eligible adults. The unadjusted estimated population HIV prevalence was 0.3% (confidence interval [CI]: 0.1-0.6%) in Thai Binh and 0.7% (CI: 0.3-1.3) in Ho Chi Minh City (HCMC), compared with the national estimates and projections of 0.352% and 1.250%, respectively, for 2005. The ratio of male-to-female prevalence was 10.5:1 in Thai Binh and 1.3:1 in HCMC. A low level of men reported purchasing sex in the last 12 months (2.4%) and there were low self-reports of sexually transmitted infections in all adults (5%). A correct knowledge of HIV/AIDS prevention methods was high in both provinces (83%), although only 24.8% of women knew of the use of antiretroviral therapy to prevent vertical transmission of HIV. The observed population prevalence was consistent with recent projections in Thai Binh, although lower than expected in HCMC, indicating the substantial downward revisions of projected population HIV prevalence may need to be extended. The unequal sex prevalence ratio is consistent with the projected trends of increasing male-to-female sexual transmission in urban areas. The results and experience of this study will inform future population based surveys in Viet Nam and the broader Asian region.

Sexual risk and bridging behaviors among young people in Hai Phong, Vietnam

The risk of the HIV epidemic spreading from high-risk groups to the general population in Vietnam depends on sexual risk and bridging behaviors between high- and low-risk individuals. A cross-sectional study was used to describe sexual activities of youth aged 18-29 years. Nearly half (41.4%) were sexually active. Premarital sex was reported by 43.3% of them; 78.3% of sexually active males and 13.5% of sexually active females. Multiple sex partners were reported by 31.0%; 56.7% of males and 9.2% of females. Almost 27% of males and 5% of females engaged in sexual bridging behaviors. Being unmarried was significantly associated with having sex with non-regular partners. Being unmarried and early age at first intercourse were associated with having sex with a sex worker. Consistent condom use was high with commercial sex workers but low with regular partners. Education to delay early sexual debut, increased employment, and strategies to inform young sexually active people to adopt safer behaviors are urgently needed.

Drug abuse in Vietnam: a critical review of the literature and implications for future research

AIMS

To provide an overall picture of drug abuse in Vietnam, its prevalence, correlates and patterns.

METHODS

Studies addressing the drug abuse problem in Vietnam are reviewed. Attention is paid to studies conducted from 1993 onwards. The reviewed studies were collected from both refereed and non-refereed sources.

RESULTS

Drug abuse is rising sharply in Vietnam: almost threefold over the past 10 years. From a predominantly rural-mountainous phenomenon, illicit drug abuse spread rapidly to urban areas. Meanwhile, the average age of drug users has declined and more women have been engaging in drug consumption. At the same time, heroin has replaced opium as the most preferred drug in the country's illicit drug market, especially among young users in urban areas. At the national level, the second main route of drug administration, injecting, has exceeded smoking and taken precedence in the country's drug abuse culture, especially among heroin users.

CONCLUSION

Drug abuse in Vietnam has changed radically over the past decade, which has implications for the national and international community and requires further research to fill the knowledge gap and to inform intervention policy for better drug control policy.

Health-seeking behaviour for sexually transmitted infections and HIV testing among female sex workers in Vietnam

This qualitative study was conducted to explore health-seeking behaviour for sexually transmitted infections (STIs) and HIV testing among female sex workers (FSWs) in the cities of Hanoi and Da Nang, Vietnam. Data were gathered from in-depth interviews, focus groups and participant observation. Results suggest that women's decision to seek STI treatment and HIV testing is influenced by the complex interplay of personal risk perceptions, social relationships and community discourse. The women exhibited adequate knowledge of HIV while their knowledge of STIs was limited. They demonstrated high-risk perceptions of HIV, but they showed little concern for STIs. Most women sought treatment at pharmacies when they noticed symptoms of the genital tract. Their decision to seek care in health facilities and HIV testing was hampered by the high costs of treatment, judgmental attitudes of service providers, and a lack of information on testing services. Future interventions need to focus on strengthening knowledge of STIs and the STI-HIV association, and increasing awareness of HIV counselling and testing services. Training for STI service providers including pharmacies and private practitioners on sex-worker friendly and non-judgmental services and counselling skills should be emphasized to provide timely diagnosis and treatment of STIs, and to refer women to HIV testing.

'Social evils' and harm reduction: the evolving policy environment for human immunodeficiency virus prevention among injection drug users in China and Vietnam

AIMS

This paper reviews the evolution of government policies in China and Vietnam regarding harm reduction interventions for human immunodeficiency virus (HIV) prevention, such as needle/syringe provision and opioid substitution treatment.

METHODS

The work is based upon the authors' experiences in and observations of these policy developments, as well as relevant government policy documents and legislation.

RESULTS

Both countries are experiencing HIV epidemics driven by injection drug use and have maintained generally severe policies towards injection drug users (IDUs). In recent years, however, they have also officially endorsed harm reduction. We sought to understand how and why this apparently surprising policy evolution took place. Factors associated with growing support for harm reduction were similar but not identical in China and Vietnam. These included the emergence of effective 'champions' for such policies, an ethos of pragmatism and receptivity to evidence, growing collaboration across public health, police and other sectors, the influence of contingent events such as the severe acute respiratory syndrome (SARS) epidemic and pressure from donors and international organizations to adopt best practice in HIV prevention.

CONCLUSIONS

Ongoing challenges and lessons learned include the persistence of tensions between drug control and harm reduction that may have negative effects on programs until a fully harmonized policy environment is established. Excessive reliance on law enforcement and forced detoxification will not solve the problems of substance abuse or of HIV among drug users. Ongoing evaluation of harm reduction programs, as well as increased levels of multi-sectoral training, collaboration and support are also needed.

Migration and transmission of blood-borne infections among injection drug users: understanding the epidemiologic bridge

Migration is one of many social factors contributing to the spread of HIV and other blood-borne or sexually transmitted infections (STI). Bringing together large numbers of people from diverse settings, the process of migration moves infected individuals to diverse geographic locations. Injection drug users (IDU) are a relatively mobile group, often moving between cities, smaller communities, and across international borders for reasons of work, security, or access to narcotics. This mobility indicates the potential for IDU who engage in risky behavior outside their home areas to transmit HIV infection to other IDU, their sex partners, and others in the population. The objectives of this review are to examine: (1) the influence of drug trafficking and the spread of drug use on the diffusion of HIV, (2) the influence of migration on drug use and HIV-related risk behaviors among migrants, and (3) the mobility patterns of IDU and its role in the spread of HIV. We also discuss the potential policy implications of addressing prevention and care issues in mobile drug using populations.

Mortality and failure among tuberculosis patients who did not complete treatment in Vietnam: a cohort study

BACKGROUND

Tuberculosis treatment failure and death rates are low in the Western Pacific Region, including Vietnam. However, failure or death may also occur among patients who did not complete treatment, i.e. reported as default or transfer-out. We aimed to assess the proportion failures and deaths among new smear-positive pulmonary tuberculosis patients with reported default or transfer-out. Treatment outcomes rates were 1.4% default, 3.0% transfer-out, 0.4% failure and 2.6% death in northern Vietnam in 2003.

METHODS

Tuberculosis patients in 32 randomly selected district tuberculosis units in northern Vietnam were followed up 1 to 3 years after treatment initiation for survival, recent treatment history and bacteriologically confirmed tuberculosis.

RESULTS

Included were 85 transferred patients and 42 who defaulted. No information was available of 41 (32%), 28 (22%) had died. Fifty-eight were available for follow-up (46%); all had sputum smear results. Tuberculosis was recorded in 11 (13%), including 6 (7%) with positive sputum smears, 3 (3%) with negative smears but positive culture and 2 (2%) who had started re-treatment for bacteriologically confirmed tuberculosis. Fifteen (17%, 95%CI 10-27%) had died within 8 months after treatment initiation. Of 86 patients with known study outcomes, 39 (45%, 95%CI 35-56%) had died or had bacteriologically confirmed tuberculosis. This was recorded for 29/53 (55%, 95%CI 40-68%) transferred patients and 10/33 (30%, 95%CI 16-49%) patients who defaulted.

CONCLUSION

The total failure and death rates are 0.6% and 0.8% higher than based on routine reporting in northern Vietnam. Although this was a large proportion of treatment failures and deaths, failure and death rates were low. Defaulting and transfer carry a high risk of failure and in particular death.

Sexual stigma, sexual behaviors, and abstinence among Vietnamese adolescents: implications for risk and protective behaviors for HIV, sexually transmitted infections, and unwanted pregnancy

As rates of HIV increase in Vietnam, there is a need for data on social relations and sexual risk and protective behaviors among Vietnamese adolescents in a context of rapid social and economic changes. The authors report results from qualitative interviews with 159 Vietnamese adolescents living in Hanoi, Nha Trang City, and Ninh Hoa District and a survey of 886 adolescents in these same three sites. In the qualitative interviews, youths report a strong adherence to ideals and values regarding abstinence outside of marriage. Youths reported low rates of engagement in vaginal, anal, and/or oral sex with a significant difference in reported behaviors between males (29/469, 6.2%) and females (7/416, 1.7%; p = .000). A total of 15 of 32 (46.9%) sexually active youths reported rarely or never using condoms. Females had significantly higher scores for perceived sexual stigma than males (t = -10.22 [95% confidence interval (CI); -3.72 to -2.52; p = .000) whereas males scored significantly lower than females on a scale of perceived self-efficacy for abstinence (t = 5.31 [95% CI; .27 to .59]; p = .000). The stigmatization of sexual relations outside of marriage particularly for young women reinforces abstinence; however, these same values decrease adolescents' ability to obtain accurate information about sexuality and HIV and sexually transmitted infections and engage in safer sex.

Impact of a community sexually transmitted infection/HIV intervention project on female sex workers in five border provinces of Vietnam

OBJECTIVES

To determine changes in the prevalence of sexually transmitted infection (STI)/HIV in female sex workers (FSWs) after a community HIV prevention intervention project in five border provinces of Vietnam.

METHODS

The project focused on providing user-friendly STI services for FSWs using mobile teams operating at multiple sites depending on local client preferences. 911 FSWs were enrolled at baseline and 982 in the exit survey. Study participants were interviewed about sociodemographic characteristics, sexual behaviour, history of STIs and selected features of their husbands or cohabiting partners, and were tested for STIs.

RESULTS

The overall prevalence rates of HIV, syphilis, herpes simplex virus 2 (HSV-2) antibodies, gonorrhoea (GC), Chlamydia trachomatis (CT), and GC and/or CT among FSWs in the five border provinces in 2004 were 3.6%, 12.9%, 24.9%, 2.9%, 9.1% and 11.3%, respectively. Compared with baseline values, GC and/or CT decreased significantly from 19.9% to 11.3%, GC from 10.7% to 2.9% and CT from 11.9% to 9.1%. HIV decreased from 4.5% to 3.6%, and HSV-2 antibodies from 27.7% to 24.9%. After adjustment for possible confounders, a significant overall decrease in having GC and/or CT (OR = 0.46, 95% CI 0.33 to 0.65; p<0.001) and GC alone (OR = 0.22, 95% CI 0.13 to 0.37; p<0.001) was found, and the overall prevalence of syphilis increased significantly (OR = 1.55, 95% CI 1.11 to 2.17 p = 0.011). A marked increase in syphilis from 1.0% to 14.1% was identified in the Lai Chau province.

CONCLUSIONS

Implementation of the project was associated with a reduction in GC and/or CT infections in FSWs, more so with GC than with CT. A notable increase in syphilis in Lai Chau was identified. HIV/STI interventions in FSWs can be implemented by government services and should be intensified and expanded to other provinces.

Changes in high-risk behaviors over time among young drug users in South Vietnam: a three-province study

Vietnam is in the midst of an expanding HIV epidemic, primarily driven by an increase in injection drug use in young people. This study was conducted to understand the patterns and initiation of drug use, and the sexual risk behavior among youth in three provinces in southern Vietnam. A cross-sectional survey was conducted among male and female drug users under age 25 recruited from drug treatment centers (N = 560) and the community (N = 240) in Ho Chi Minh City, Dong Nai and Ba Ria-Vung Tau. The majority of those surveyed (82%) began by smoking heroin; after a year, 57% were injecting heroin and/or opium. Initiation of drug use frequently occurred in entertainment venues. Among injectors, 23% shared needles; 71% of all users were sexually active of whom 77% had unprotected sex. More than half of those recruited from treatment centers had previously been in drug treatment. Public health programs to prevent and treat the dual epidemics of HIV and drug abuse must be able to access and respond to the needs of youth, many of whom are unemployed and exposed to drug traffic.

High HIV sexual risk behaviors and sexually transmitted disease prevalence among injection drug users in Northern Vietnam: implications for a generalized HIV epidemic

BACKGROUND

HIV prevalence in Vietnam is currently concentrated among injection drug users (IDUs). The extent to which this core risk group represents a potential for broader HIV transmission to the general population is currently unknown.

METHODS

A community-based cross-sectional study among IDUs in Vietnam assessed sexually transmitted disease (STD) prevalence and behavioral risk factors. Qualitative interview data enhanced quantitative findings.

RESULTS

The prevalence of any STDs among 272 IDUs was 30% (chlamydia, 9%; herpes simplex virus type 2 [HSV-2], 22%; gonorrhea, 0%; and syphilis, 1%). Part-time work or unemployment (odds ratio [OR] = 2.74, 95% confidence interval [CI]: 1.1 to 6.9), sex with > or =2 sex workers in the past year (OR = 4.9, 95% CI: 1.91 to 12.6), having ever smoked heroin (OR = 4.5, 95% CI: 1.1 to 18.3), and injecting less frequently than daily (OR = 3.9, 95% CI: 1.43 to 10.6) were independently associated with chlamydial infection. Urban residency (OR = 4.0, 95% CI: 1.4 to 11.0) and daily injecting (OR = 2.2, 95% CI: 1.1 to 4.4) were independently associated with HSV-2. Odds of HSV-2 among older (> or =28 years of age) IDUs who had sex with <2 sex workers in the past year was higher than among younger IDUs who had sex with more sex workers (OR = 6.4, 95% CI: 2.1 to 18.4).

CONCLUSIONS

High STD prevalence and high-risk sexual and parenteral behaviors among IDUs indicate the potential for HIV/STD transmission to the general Vietnamese population.