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Funding Support. National Institute on Drug Abuse, U.S. National Institutes of Health – Research Ford Foundation (Beijing and Hanoi) – Interventions. Overview. Geographic Setting Cross-Border Dimensions of Drug Use and HIV Transmission Cross-Border HIV Prevention Project. - PowerPoint PPT Presentation
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NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
Funding SupportFunding Support
National Institute on Drug Abuse, U.S. National Institutes of Health – Research
Ford Foundation (Beijing and Hanoi) – Interventions
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
OverviewOverview
Geographic Setting
Cross-Border Dimensions of Drug Use and HIV Transmission
Cross-Border HIV Prevention Project
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
Geographic SettingGeographic Setting
China
Vietnam
ChinaVietnam
Hanoi
Area of Detail
Ning Ming City
Langson town
Puzhai
Tan ThanhDong Dang
Loc Binh
Tongmian
ShilangAidian
Large Project Site
Small Border Site
Key:
Map of Project Sites
Hop Thanh
CaoLoc Town
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
Cross-Border DimensionsCross-Border Dimensions1.1. Drug Trafficking Drug Trafficking Drug Use Drug Use HIV Transmission HIV Transmission
Drug Trans-shipment RoutesGolden Triangle Vietnam S. China Hong Kong The World
Source: Beyrer et al., AIDS 2000; 14:75-83
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
Drug Trafficking Drug Trafficking Drug Use Drug Use HIV HIV TransmissionTransmission
Heroin availability along trans-shipment routes shift from traditional opium smoking to heroin smoking/ inhalation heroin injection (cost efficiency)
Heroin injection sharing of injection equipment (pharmacy sale of needles/syringes but problems of cost [users often cannot afford needle/syringe once they pay for drug], and limited business hours)
Sharing of injection equipment HIV transmission
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
Guangxi Province, China: HIV spreads along drug trans-Guangxi Province, China: HIV spreads along drug trans-shipment routesshipment routes
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
Guangxi Province, China: HIV spreads along drug trans-Guangxi Province, China: HIV spreads along drug trans-shipment routesshipment routes
• 21% HIV prevalence among IDUs in Pingxiang (adjacent to Ning Ming), 21% HIV prevalence among IDUs in Pingxiang (adjacent to Ning Ming), ~~10% in 10% in Ning Ming (awaiting Cross-Border project baseline survey – July 2002)Ning Ming (awaiting Cross-Border project baseline survey – July 2002)
Source: Guangxi Center for HIV/AIDS Prevention and Control
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
Vietnam: Increasing HIV prevalence among IDUs Vietnam: Increasing HIV prevalence among IDUs along border with Guangxialong border with Guangxi
Quang Ninh Province – 65% HIV prevalence among IDUs (Sentinel Surveillance, 2000)
Lang Son Province – increasing numbers of cases
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
Vietnam: Increasing HIV prevalence among IDUs Vietnam: Increasing HIV prevalence among IDUs along border with Guangxialong border with Guangxi
• Lang Son: Lang Son: ~~80% of HIV cases are IDUs, 80% of HIV cases are IDUs, ~~21% HIV prevalence among IDUs 21% HIV prevalence among IDUs (Sentinel Surveillance, 2000) – but concern about sampling makes figure (Sentinel Surveillance, 2000) – but concern about sampling makes figure uncertain. Awaits Cross-Border project baseline survey – July 2002uncertain. Awaits Cross-Border project baseline survey – July 2002
8.25
13.1
21.3
0.18
13.9
23.3
0
5
10
15
20
25
30
1996 1997 1998 1999 2000 2001
%
HIV Prevalence Among IDUs in Lang Son, HIV Prevalence Among IDUs in Lang Son, 1996-20011996-2001
Source: Preventive Medicine Center of Lang Son, December, 2001
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
Cross-Border DimensionsCross-Border Dimensions
2.2. Small-scale movement associated with heroin Small-scale movement associated with heroin purchase/salepurchase/sale Molecular epidemiology (Beyrer, 2000; Yu, 1998, 1999, 2002; Kato,
1999) suggest cross-border HIV transmission probably from N. Vietnam S. China: matching strains of Subtype E found on both sides of border
Border between Guangxi and Lang Son – 200 km, mountainous, porous – 1 official crossing, 5 semi-official, many unmonitored
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
SmallSmall-scale movement associated with heroin purchase/sale (cont.).) Patterns of movement – influences (from formative research, more
to come from project surveys): Price (lower) and purity (higher) in Vietnam – Chinese users
cross into Vietnam to buy/use Law enforcement activity Wholesale/retail availability: Chinese dealers buy in Lang Son,
sell in Ning Ming; Vietnamese users cross into China to buy/use
Vietnamese IDUs/sex workers live in China (e.g., 30% of IDUs in Aidian are Vietnamese)
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
Cross-Border DimensionsCross-Border Dimensions
3.3. Trade and EmploymentTrade and Employment Legitimate business/commercial activity
Migratory labor
“Floating Population” – 1 million in area
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
Cross-Border DimensionsCross-Border Dimensions
4.4. Ethnic/Family TiesEthnic/Family Ties Common ethnic minority groups on both sides of border (e.g.,
Zhuang)
Intermarriage common, although illegal and results in loss of nationality.
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
Cross-Border HIV Prevention ProjectCross-Border HIV Prevention Project
First-ever cross-border HIV prevention project for IDUs
HIV prevalence at possible “take-off” point in Ning Ming and Lang Son
Cross-border dimensions and opportunities project concept and design
Project development: 1997-2001 – many challenges
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
InterventionIntervention
6 sites in Lang Son, 4 in Ning Ming
Peer-based education of IDUs Centers in Ning Ming/Field outreach in Lang Son
Public health/infection control Collection and safe disposal of used needles/syringes
Social marketing of new needles/syringes Pharmacy/clinic vouchers (China and Vietnam) Direct exchange also offered (Vietnam)
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
Intervention (cont.)Intervention (cont.)
Community education Letters of support from police and other agencies Regular meetings/community workshops
Job training for peer educators
Support for drug use cessation
Cross-border collaboration
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
Pharmacy/Clinic Voucher Pharmacy/Clinic Voucher – Lang Son Province– Lang Son Province
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
Pharmacy/Clinic Voucher Pharmacy/Clinic Voucher – Lang Son Province– Lang Son Province
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
EvaluationEvaluation Methods
Pre- and multiple-post intervention followup— Cross-sectional surveys of IDUs (baseline + 6, 12, 24, 36
months)— HIV testing (with counseling)— “Capture-recapture” component HIV incidence estimation,
longitudinal behavior change KAP surveys in community (HIV knowledge, knowledge of/attitudes
toward project) Process data
— Peer educator logs (contacts, collection of used needles/syringes)
— Pharmacy/clinic logs (vouchers redeemed)
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
Evaluation (cont.)Evaluation (cont.) Outcomes
Stable HIV prevalence Low HIV incidence Reduced high-risk behavior (distributive and receptive sharing of
injection equipment) Reduced high-risk sexual activity Large-scale safe disposal of used needles/syringes Increased community awareness of HIV and support for
intervention
NIDA Satellite Meeting: Effects of Drug Use and High Risk Behavior on HIV Transmission Across National Borders, XIV International AIDS Conference, Barcelona, July 9, 2002
ConclusionsConclusions
Path-breaking project
Very important opportunity to reduce cross-border HIV transmission and increase cross-border collaboration
Serious challenges in development and implementation
Collaboration in cross-border projects would be useful in many HIV transmission contexts in many parts of the world