Funding Support

World Bank Inter-Country Consultation, Kolkata: April 11, 2007World Bank Inter-Country Consultation, Kolkata: April 11, 2007

Funding SupportFunding Support

National Institute on Drug Abuse, Grant No. 1 R01 DA-14703; Anonymous donor in NYC – Research and evaluation

Ford Foundation (Beijing and Hanoi), Global Fund, National and Provincial budgets – Interventions

Address for Correspondence:

Theodore M. Hammett, Ph.D.Abt Associates Inc.55 Wheeler StreetCambridge, MA 02138 [email protected]


BackgroundBackground

Cross-Border movement Drug Trans-shipment Routes Heroin Use Heroin Injection

HIV Transmission Increasing HIV Prevalence Cross-Border Transmission (Molecular epidemiology: Beyrer et al., AIDS, 2000)

Small-scale movement across long, porous border

Trade, migratory employment, “floating population”

Intermarriage, ethnic minority groups on both sides

Emerging evidence of sexual transmission and epidemic generalization.


Geographic Setting of Cross-Border ProjectGeographic Setting of Cross-Border Project

China

Vietnam

Hanoi

Area of Detail

Large Project Site

Small Border Site

Key:

Vietnam

China

Ning Ming City

Lang Son City

Puzhai

Tan ThanhDong Dang

Loc Binh

Tongmian

ShilangAidian

Hop Thanh

CaoLoc Town

Ha Giang Guigang

PDI Site


Near the border at Aidian, ChinaNear the border at Aidian, China


Border scene at Aidian, ChinaBorder scene at Aidian, China


Border traffic, Vietnam side Border traffic, Vietnam side


InterventionsInterventions

Peer-based education of IDUs, sex workers, and sexual partners of IDUs

Distribution of needles/syringes and condoms – directly and through redemption of pharmacy vouchers

Collection/safe disposal of used needles/syringes

Community education

Support for drug use cessation

Full implementation of IDU interventions began inFull implementation of IDU interventions began in 2002; Women 2002; Women at Risk interventions began in 2006.at Risk interventions began in 2006.

Will present mainly on results of IDU interventions.


Pharmacy/clinic in Tongmian, ChinaPharmacy/clinic in Tongmian, China


Needle/Syringe Distribution by a Village Doctor, Near Needle/Syringe Distribution by a Village Doctor, Near Ning Ming City, ChinaNing Ming City, China


Discarded wrappers and needles/syringes, Discarded wrappers and needles/syringes, Lang Son CityLang Son City


Basket for collection of used needles/syringes, Basket for collection of used needles/syringes, Loc Binh, VietnamLoc Binh, Vietnam


Cross-Border collaborationCross-Border collaboration

Joint meetings every 6 months-1 year to share experiences, strategies, and evaluation results – host country alternates.

Bonds formed between Vietnamese and Chinese partners.

Peer educators from Tan Thanh, Vietnam site cross border every week to work with Vietnamese sex workers in Puzhai (Pingxiang), China in collaboration with Chinese officials and agencies.

Study tours from China to Vietnam.

Policy advocacy in both countries.


EvaluationEvaluation

Methods Pre- and multiple-post intervention follow-up

— Cross-sectional surveys of IDUs —Baseline, 6-, 12-, 18-, 24-, and 36-month completed in China and Vietnam

— HIV testing (with counseling)

— HIV incidence estimation (repeat participants/new injectors)

KAP surveys in community (HIV knowledge, knowledge of/attitudes toward project) — same intervals as IDU surveys

Process data

— Peer educator logs (contacts, collection of used needles/syringes)

— Pharmacy/clinic logs (vouchers redeemed)


Process indicatorsProcess indicators Interventions reach ~50-87% of IDUs, depending on site and

survey wave.

~20,000 – 25,000 new needles/syringes provided per month.

~4,000 – 6,000 condoms distributed per month.

~15,000 – 20,000 used needles/syringes collected per month.

IDUs in Vietnam generally prefer pharmacy vouchers (except in sites with few participating pharmacies), while in China they prefer direct distribution.

Police have not directly interfered with interventions, but periodic crackdowns on IDUs may reduce participation – monthly average number of needles/syringes provided has gone down in China sites.

Public health scale intervention: Providing ~80 new needles/syringes per IDU per year (compares favorably to NYC where prevalence/incidence substantially reduced).


Drug-Related Risk Behaviors, Past 6 Months: Drug-Related Risk Behaviors, Past 6 Months: Lang Son Province, VietnamLang Son Province, Vietnam

Lang Son Province

0%

10%

20%

30%

40%

50%

60%

Basel

ine

6-M

onth

12-M

onth

18-M

onth

24-M

onth

36-M

onth

Receptive sharing of needles or syringes

Distributive sharing of needles or syringes

Shared any injection equipment


Drug-Related Risk Behaviors, Past 6 Months: Drug-Related Risk Behaviors, Past 6 Months: Ning Ming County, ChinaNing Ming County, China

0%

20%

40%

60%

80%

Baseline 6-Month 12-Month 18-Month 24-Month 36-Month

Receptive sharing of needles or syringes

Distributive sharing of needles or syringes

Shared any injection equipment


Other risk factorsOther risk factors

Contrary to popular mythology, many IDUs are sexually active.

More IDUs in Ning Ming report patronizing sex workers and having unprotected sex with casual partners.

Self-reported cross-border drug purchase and injection are surprisingly infrequent, but pose very high risk for IDUs crossing from China to Vietnam (data not shown).


HIV Prevalence by SiteHIV Prevalence by Site

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%


Ning Ming County, China Lang Son Province, Vietnam


Comments on HIV Prevalence PatternsComments on HIV Prevalence Patterns HIV Prevalence among IDUs is stable or declining in Lang Son and Ning Ming

over 36 months, unlike pattern in other nearby sites (Yunnan, China and Quang Ninh and Haiphong, Vietnam).

In Lang Son and Ning Ming, there is a gradient of HIV prevalence among the sites running in descending order from sites farthest from the border in Vietnam to the sites the farthest from the border in China (data not shown).

There is a similar gradient for self-reported length of injection history by distance from the border, i.e., IDUs in Lang Son tend to have been injecting longer than those in Ning Ming (data not shown).

These gradients are consistent with the spread of heroin injection and HIV along drug transshipment routes, but more slowly than might have been expected.

Stability of gradient pattern and actual prevalence rates, together with declining incidence, suggests control of cross-border and intra-country transmission of HIV.


Estimating Incidence in New InjectorsEstimating Incidence in New Injectors

New injectors: those reported having injected <3 years;New injectors: those reported having injected <3 years;

Assume all new injectors HIV seronegative when they start Assume all new injectors HIV seronegative when they start to inject;to inject;

Assume all HIV seropositive new injectors became infected Assume all HIV seropositive new injectors became infected halfway between time of first injection and time of halfway between time of first injection and time of interview;interview;

Incident cases of new infections equal number of HIV Incident cases of new infections equal number of HIV seropositive new injectors in each survey;seropositive new injectors in each survey;

Time at risk equals sum of times from first injection to Time at risk equals sum of times from first injection to interview for all HIV seronegatives plus 1/2 time from first interview for all HIV seronegatives plus 1/2 time from first injection to interview for HIV seropositives.injection to interview for HIV seropositives.


New Injectors: Lang Son ProvinceNew Injectors: Lang Son Province

%HIV+ (Prev.)%HIV+ (Prev.) Mean Yrs Mean Yrs InjectingInjecting

Est. HIV Est. HIV IncidenceIncidence

baselinebaseline 31 %31 % 1.57 yr.1.57 yr. 20 %/yr.20 %/yr.

6 mo.6 mo. 27 %27 % 1.31 yr.1.31 yr. 21 %/yr.21 %/yr.

12 mo.12 mo. 21 %21 % 1.29 yr.1.29 yr. 17 %/yr.17 %/yr.

18 mo.18 mo. 19 %19 % 1.37 yr.1.37 yr. 14 %/yr.14 %/yr.

24 mo.24 mo. 13 %13 % 1.41 yr.1.41 yr. 9 %/yr.9 %/yr.

36 mo.36 mo. 6 %6 % 1.29 yr.1.29 yr. 4 %/yr.4 %/yr.


New Injectors: Ning Ming CountyNew Injectors: Ning Ming County

%HIV+ (Prev.)%HIV+ (Prev.) Mean Yrs Mean Yrs InjectingInjecting

Est. HIV Est. HIV IncidenceIncidence

baselinebaseline 16 %16 % 1.50 yr.1.50 yr. 11 %/yr.11 %/yr.

6 mo.6 mo. 22 %22 % 1.22 yr.1.22 yr. 18 %/yr.18 %/yr.

12 mo.12 mo. 11 %11 % 1.25 yr.1.25 yr. 9 %/yr.9 %/yr.

18 mo.18 mo. 9 %9 % 1.30 yr.1.30 yr. 7 %/yr.7 %/yr.

24 mo.24 mo. 11 %11 % 1.36 yr.1.36 yr. 8 %/yr.8 %/yr.

36 mo.36 mo. 0 %0 % 1.29 yr.1.29 yr. 0 %/yr.0 %/yr.


HIV Incidence Among New Injectors, by SiteHIV Incidence Among New Injectors, by Site

0%

5%

10%

15%

20%

25%


Ning Ming County, China Lang Son Province, Vietnam


Knowledge and Attitudes in the Community:Knowledge and Attitudes in the Community:Ning Ming County, ChinaNing Ming County, China

“Correct” Answers Baseline6-

Month12-

Month18-

Month24-

Month36-

Monthp-value

(n=321) (n=343) (n=346) (n=312) (n=317) (n=298)

Transmitted through needle sharing 93% 95% 89% 93% 84% 93% 0.04

Not transmitted by touching or hugging an HIV+ person 75% 84% 86% 89% 90% 93% <0.001

Not transmitted through eating with HIV+ person 55% 67% 71% 67% 76% 81% <0.001

Will reduce discarded needles/syringes 57% 71% 58% 63% 74% 68% 0.003

Will reduce spread of HIV 75% 79% 76% 70% 73% 76% 0.238

Will not increase drug use 62% 61% 68% 63% 53% 54% 0.003


Knowledge and Attitudes in the Community: Knowledge and Attitudes in the Community: Lang Son Province, VietnamLang Son Province, Vietnam

“Correct” Answers Baseline6-

Month12-

Month18-

Month24-

Month36-

Monthp-value

(n=250) (n=250) (n=250) (n=250) (n=250) (n=250)

Transmitted through needle sharing 100% 97% 98% 100% 100% 97% 0.771

Not transmitted by touching or hugging an HIV+ person 90% 86% 87% 93% 94% 86% 0.484

Not transmitted through eating with HIV+ person 79% 87% 85% 96% 89% 88% <0.001

Will reduce discarded needles/syringes 97% 98% 98% 99% 100% 96% 0.71

Will reduce spread of HIV 97% 98% 99% 98% 99% 96% 0.505

Will not increase drug use 71% 67% 69% 82% 84% 77% 0.002


ConclusionsConclusions This is an innovative project, offering important opportunities to

control a cross-border HIV epidemic and increase cross-border collaboration.

The interventions are reaching substantial proportions of IDUs and providing public health scale distribution of new needles/syringes.

Drug-related HIV risk behaviors are being reduced.

HIV prevalence among IDUs is stable or declining.

Cross-border prevalence differential has been maintained; HIV prevalence has not risen to levels found in other nearby places.

HIV transmission has not been halted, but incidence among new injectors is coming down.

Evaluation results have had positive effects on policy development, in terms of support for harm reduction strategies.

Funding Support

Documents

Transcript of Funding Support