Substance Use Disorders and HIV in Vietnam since Doi Moi (Renovation):

An Overview

LE MINH GIANG1, LUNG BICH NGOC1, VU HUY HOANG2, KEVIN MULVEY2, RICHARD RAWSON3

1. Vietnam-HIV Addiction Technology Transfer Center (VHATTC), Hanoi Medical University, Vietnam

2. SAMHSA, US Embassy Hanoi3. Integrated Substance Abuse Program, UCLA

Vietnam HIV Addiction Technology Transfer Center

1

1. Changing patterns of substance use and abuse since early 1990s

2. HIV epidemic and the role of substance abuse

3. Responses to SUD and HIV: successes and gaps

4. Current research capacity and research needs

Topics

2

Most popular drugs in Vietnam(reported drug of choice among caught users)

Drug of choice 1995 2001 2005 2012

Amphetamine-type stimulants

N/A

0%

3

1,5%

3

2,5%

2

6,5%

Heroin 2

1,4%

1

29,3%

1

88,6%

1

84,7%

Opium 1

92,7%

2

66,8%

2

27,8%

3

6,4%

Source: DSEP/MoLISA (1995, 1999, 2001, 2005); National Commission on AIDS, Drug and Prostitution (2012). 3

Source: UNODC (2012b)

Increasing both heroin and Methamphetamine

4

Frequency of using Methamphetamine the last 90 days

Heroin users

MSM FSWs ATS users Taxi drivers Bar goers

2500.0% 2060.0%

3960.0%

470.0%

2550.0%1690.0%

1690.0% 2060.0%

1570.0%

1090.0%

1380.0%

870.0%

3140.0%4430.0%

3360.0%

3750.0%

4360.0%

4770.0%

2670.0%1450.0% 1120.0%

4690.0%

1700.0%2670.0%

Several times per week Once per weekSeveral times per month Once or twice in last 90 days

Source: UNODC (2012a) 5

Concurrent use of heroin and other drugs

Source: PSI (2012): BS Survey6

Crystal Meth Marijuana Amphetamine All others (Pipolpen, Opium…)

15%

7.0%

2.8% 3.0%

Heroin users in a 2012 survey reported using the a wide range of other drugs in the past 12 months

Drug use prevalence among FSWEver used drugs (NIHE IBBS 2009)

7

Drug use risk among FSW

Source: MOH (2012) 2009 -2010 IBBS results; Courtesy of Linh-Vi Le (CDC, 2013)

Adjusted OR*

95% CIAdjusted

OR**95% CI

Never used 1 — 1 —

Non-injecting drug use only 1.73 1.17, 2.56 2.32 0.78, 6.92

Injecting drug use 3.18 2.25, 4.49 26.07 14.38, 47.27

High HIV prevalence provinces

Low HIV prevalence provinces

Illicit drug use (lifetime)

* Adjusted for age, condom use, where meet clients, and province** Adjusted for marital status, condom use, knowledge, where meet clients, and province

“Injecting drug use is the key risk factor of HIV infection among FSW in Vietnam, and attention needs to be paid especially to FSW in provinces with newer epidemics” (MOH 2012)

8

Summary 1: Changing patterns past two decades

• Mostly men1,5,

• And yet drug use among FSWs has driven the HIV epidemic in this population 4,5

• Heroin are the most used: 65% - 85%1,5 ;

• Mean interval of transition from heroin smoking to injection was 2.5 years3 and became increasingly shorter among heroin initiates3,4.

• ATS consumption has rapidly increased after 20082.

Source: 1.Do et al. 2012; 2.UNODC 2012; 3. Clatts et al.2011; 4.Thao et al. 2006; 5.Tam T.M Nguyen et al. 2012 9

Projection of HIV transmission in Viet Nam to 2015

0

5,000

10,000

15,000

20,000

25,000

30,000

IDU FSW Client Low Risk Female Low Risk Male

Num

ber o

f new

infe

ction

s

Source: MOH (2012) EPP 2011 - 201510

Share of injecting drug use among HIV reported

11

2001' 2002' 2003' 2004' 2005' 2006' 2007' 2008' 2009' 2010' 2011' 2012'0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

1.6%1.5%

1.3%

1.4%

1.3% 0.8% 0.6%

0.9%

0.5% 0.6% 0.8% 0.6%

51.1%49.5%

45.1%42.5%

38.9% 40.5% 36.6%

45.3%

45.0% 43.9%41.8%

37.7%

2.6%3.0% 2.8% 3.2% 3.8% 5.3%

8.1%13.1%

16.9% 19.4% 22.5%24.7%

Không ro Khác STDs Lao Gái MD

Nghi AIDS NCMT Tinh duc khác giơi Các nhóm còn lại

Source: VAAC (2012)

Vietnam IDU-HIV Twin Epidemics

MOH (2012) 2009 – 2010 IBBS Results; VAAC (2013) Annual report; Nguyen (2013) – Courtesy of Dr. Todd Korthuis

26% of IDU HIV-infected (1-56% by province)

IDU Population

(n=336,000)

62% report history of IDU at ART initiation

HIV-infected Population (n=248,245)

Projection of HIV prevalence among IDUs to 2015

Source: MOH (2012) EPP 2011 - 2015

HIV prevalence among IDU at national level is approximately 30%1

The epidemic among IDU in Northwestern region is speedily rising1

0

10

20

30

40

50

60

70

80

HIV

pre

vale

nce (%

)

Hanoi 1 Quang Ninh Nghe An North West

An Giang Can Tho Hai Phong HCMC - Young IDUs

HCMC-Old IDUs National prevalence

13

Source: MOH (2012)

Map of HIV prevalence among IDUs in Vietnam (2011)

14

IDU MSM SSW VSW

HBs Ag (+)

Mean 15.1 15.9 11.7 11.2

Median 14.7 12.3 10.8 10.8

IQR 12.1-16.8 11.0-20.7 9.7-12.0 8.4-13.3

HBs Ag (-) & Anti-HBC (+)

Mean 58.7 45.1 55.6 46.1

Median 59.5 45.2 56.6 47.9

IQR 53.5-64.2 40.0-49.7 52.6-62.7 37.3-52.2

HCV Ag/Ab (+)

Mean 58.0 26.1 n/a n/a

Median 57.4 24.8 n/a n/a

IQR 44.7-75.6 17.3-34.8 n/a n/a

Prevalence of HBV and HCV infection among high risk groups in 2009

Source: 2009 – 2010 IBBS Results 15

ALL AG CT DI DN HCM HN HP NA QN YB0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

%

Source: 2009 – 2010 IBBS Results

Current or previous infection of HCV among IDUs in 2009

16

HCV prevalence since first injection (2006)

Source: Clatts et al. (2009) 17

Needle and syringe sharing (2009)

Proportion of IDU reporting needle and syringe sharingSource: MOH (2012) 2009 – 2010 IBBS Results

18

Total <25 yr 25+ yr Total <25 yr 25+ yr Total <25 yr 25+ yrFSWs

(with most recent client)MSM

(anal sex with male partner)Male IDUs

(at last sex)

0

20

40

60

80

100

78 79 77

6670

64

52 54 51

%

Reported condom use at last sex by age group (2009)

Source: www.aidsdatahub.org 19

Reported condom use over the past 12 months (comparing 2006 and 2009)

Source: MOH (2012) 2009 – 2010 IBBS Results 20

Projected number of adults aged 15 and older living with HIV, by sex

Source: MOH (2007) EPP to 201221

Women’s exposure to HIV from their IDU partners

22

All male IDU: 192,406

IDU with a wife:40.4%

HIV(+) IDU:28.0%Married &

HIV(+):12.3%

Courtesy of Lam et al (2012)

Estimate of IPT magnitude - IDU partners

HIV cases detected in

women attributable to IDU partners

= 1,739

Women tested at VCT, 2006-2010: 110,277

Women with personal or other risk exposures

Exposed to IDU partners and tested negative at VCT = 13,406

Undetected IPT

All women exposed to IDU positive partners: 23,666

Courtesy of Lam et al (2012) 23

HIV testing: comparing 2006 and 2009 IBBS

2006

2009

2006

2009

2006

2009

FS

Ws

MS

MM

ale

IDU

s

0 20 40 60 80 100

15

35

16

19

11

18

%

Source: www.aidsdatahub.org; NIHE (2012) Results of HSS+ 24

2012: 31.27% of IDUs have tested and returned for HIV testing result in the last 12 months

Vietnam HIV Care Cascade

Out of 248,485 Vietnamese Living with HIV…

197,335 know they are infected

72,213 linked to care

60,924 receive ART

? suppressed

79%

29%

25%

VAAC (2013) Annual report;

19 %

? %

48,230 retained in care 24 mo

IDU vs. non-IDU Initiating ART in Vietnam

IDU Non-IDU

CD4 count < 50 40.1% 32.3%

WHO stage III/IV 82.7% 68.4%

TB 16.2% 10.0%

HCV 52.6% 18.1%

Alive & retained on ART 12 months 24 months 36 months 48 months

81.5%73.6%67.4%63.3%

90.1%88.2%88.2%85.7%

Nguyen et al (2013)

Adherence to ART among IDUs vs. non-IDU

27Source: Nguyen et al (2013)

• Patients who are IDUs were significantly poorer in retention than non-IDUs

Alcohol abuse among HIV positive drug users during ART

28

• A large sample drawn from OPCs and hospitals in three cities: 30.1% reported hazardous drinking and 22.3% binge drinking

• Among HIV positives who were on ART, drug users (DUs) had higher alcohol consumption and likelihood of alcohol use disorders (1.27 times) than non-Dus

• DUs in the 1st year ART had higher alcohol consumption and possibility of at-risk drinking than DUs who were on waiting list

• HIV positive DUs who were receiving Methadone were less likely to be at-risk drinking (0.56 times)

Source: Tran X. Bach et al. (2013)

From “social evil” to “patient”: shifting discourse and action

• Drug use was considered as “social evil” (tệ nạn xã hội): Drug users needed re-education and rehabilitation.

• 1993: The Resolution 06/CP gave birth to Compulsory Centers (06 centers);

• New discourse since about 2006: drug users as patients, removing drug use behavior from the Penal code in 2009

• Methadone was piloted in 2008 and then scale up

• And yet more than 120 compulsory centers with the capacity of about 70,000 drug users are maintained

Source: Thu Vuong et al (2012) 29

Impacts of needle and syringe coverage 2005 - 2009

Source: VAAC, UNW, UNAIDS, PEMA (2010)30

MMT National Scale-Up: Status and Plan• Current MMT program

– 20 provinces– 59 clinics, 1 satellite – 12,292 (through December 2012)

• Implementation Landscape: 60 Clinics– USAID: SMART TA: 17– CDC: LifeGap 16

HCMC03

– Global Fund & WB, HAARP: 24 – Provincial Requests for 58 new clinics to

open in 2013• Technical Assistance (TA) landscape:

– CDC/FHI 360 (50 PEPFAR-funded clinics)– MoH/VAAC request to PEPFAR for TA

Support in 30 provinces and for all programs

31

Changes in QoL of HIV+ methadone users

Source: Tran BX et al.2012 32

33

HIV Rates in MMT in 2012 20 Cities/Provinces

0

500

1,000

1,500

2,000

2,500

3,000

3,500

HIV+ Positive

HIV- Negative

16.9%

46.4%

?? %

Source: VAAC (2012); Courtesy of Dr. Banys

477 HIV related peer-reviewed publications 2005 - 2011

HIV E

pi

STIs, T

B Epi

Genet

ic

Behav

iors

Educa

tion

& BCC

Needl

e & S

yrin

ges

Comdo

m

Testin

gM

MT

Combi

natio

n of

Pre

vent

ion

ARV trea

tmen

t

Health

care

serv

ice

Law, e

thics

/pol

icy

Stigm

aOth

er0

10

20

30

40

50

60

70

8074

31

14

29

10 11

22

15

710

8

14

HIV positiveIDUsFSWsMSMCombination of high risk group Anternatal/MCTSpouses of PLHIVMobile populationClients of FSWsSpouses of IDUsMinorityYoung peopleClients of health care servicesGovernment health officialsThe general populationOthers

Total publication on IDUs: 81/477 (17%)

Source: CDC & FHI (2012)

Studies

Summary 2: Lots of successes; remained key challenges

• Changing patterns of drug use and abuse: – Heroin and HIV epidemic moving rapidly to remote provinces– ATS use on the rise in urban settings, most problematic

among MSM, FSW and methadone patients (threat to success) and yet lack real data

• Expansion of methadone program with endorsement by the government (Degree 96 in November 2012)– Challenges in maintaining high quality– Challenges in settings and individuals not ready for MMT

• Cascade of IDUs access to HIV services (testing, registered to care, OPC, retention in ARV) – Lack of integration of addiction and HIV services

35

Research needs in Vietnam

• How to improve integration of SUD and HIV services• What are and how to introduce other alternatives to MMT,

especially for settings and individuals out-of-reach with MMT • How to reach IDU at critical junctures where they are most

vulnerable and yet have better chance to be connected to services (e.g. before release from 06 centers)

• How to address epidemics among other highly vulnerable groups: women partners of IDUs (esp. MMT clinics are opening up this opportunity), female sex workers, MSM

• How to capture and understand better changing epidemics, e.g. ATS and HIV linkage; changing patterns of drug use, especially injection risks

• What is the shape of future workforce: role of professionals? role of para-professionals? cost-effectivness? 36

ACTIVE NIH-FUNDED STUDIES RELATED TO HIV AND DRUG USE IN VIETNAM

Topic Institution Institution country collaboration

Year

Male IDUs in Vietnam: Ethno-epidemiology of HIV risk

University of Puerto Rico (PI: Michael Clatts)

Hanoi Medical University

2003-2008

HIV infection in drug users in two international sites

Tufts University(PI: Sherwood Gorbach)

National Institute of Infectious & Tropical Diseases

2006-2010

Feasibility of pharmacy-based HIV intervention among IDUs: Ha Giang, Vietnam

ABT Associates(PI: Seligman)

Ha Giang Provincial Health Centre

2009-2010

Diffusion of HIV1 among MSWs in SE ASIA

University of Puerto Rico (PI: Michael Clatts)

Hanoi Medical University

2007-2011

Prevention for positives: RCT among Vietnamese with HIV

JHU (PI: Vivian Go) Thai Nguyen Centre for Preventive Medicine

2007 – 2011

ACTIVE NIH-FUNDED STUDIES RELATED TO HIV AND DRUG USE IN VIETNAM

Topic Institution Institution country

collaboration

Year

Development of Family Intervention to Address drug use and HIV in Vietnam

UCLA (PI: Li Li) National Institute of Hygiene and Epidemiology

2010 – 2011

Seek, test, treat strategies for Vietnamese drug users: A random controlled trial

Johns Hopkins University (PI: Quan, Vu Minh)

2010-2015

Implementation of a sexual health intervention for YMSM in two Vietnamese cities

National Development & Research Institutes(PI: Goldsamt Lloyd)

Hanoi Medical University

2012-2017

Enhancing the role of commune health workers in HIV and drug control in Vietnam

UCLA (PI: Li Li) National Institute of Hygiene and Epidemiology

2012-2017

A pilot implementation project of methadone and suboxone for injecting drug users

University of Pennsylvania (PI: O’Brien, Charles P)

Esther and HCMC AIDS Committee

2012-2017

Many important publications (selected)

39

Vietnam-HIV Addiction Technology Transfer Center

THANK YOU FOR YOUR ATTENTION

AND SUPPORT

40

References

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42

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• www.aidsdatahub.org (accessed April 02, 2013)• Various annual reports from National Commission on AIDS, Drugs and Prostitution (2012);

DSEP/MoLISA (1995, 1999, 2001, 2005); VAAC (2012)• Courtesy of presentation by Linh-vi Le (CDC, 2013); PSI (2012): BS Survey; Todd Korthuis

(2013) 43