Tài liệu Risk behaviors for hiv transmission and effectiveness of preventive intervention in the injection drug users in quang nam province

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MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY ----------------------------- TRAN VAN KIEM RISK BEHAVIORS FOR HIV TRANSMISSION AND EFFECTIVENESS OF PREVENTIVE INTERVENTION AMONG INJECTING DRUG USERS IN QUANG NAM PROVINCE Specialization: Epidemiology Code: 62.72.01.17 SUMMARY OF THE PHILOSOPHY DOCTOR THESIS HANOI - 2014 The study was completed in National Institute of Hygiene and Epidemiology The scientific supervisors: 1. Prof. Nguyen Thanh Long 2. Assoc. Prof. Nguyen Thi Hong Hanh Opponent 1: Assoc. Prof. Doan Huy Hau, Vietnam Military Medical University Opponent 2: Prof. Dao Van Dung, Central Party's Commission for Popularization and Education Opponent 3: Assoc. Prof. Nguyen Minh Son, Hanoi Medical University The thesis will be defended at the meeting hall of the National Institute of Hygiene and Epidemiology. In ………………… The thesis is available at: 1. The National Library 2. The Library in National Institute of Hygiene and Epidemiology ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome ARV Anti Retrovirus ASP Accidental sexual partner EI Effective indicator FSW Female sexual worker HIV Human Immuno deficiency Virus IDU Injection drug user OR Odds Ratio STIs Sexually Transmitted Infections UNAIDS Joint United Nations Programme on HIV/AIDS WHO World Health Organization PUBLICATIONS 1. Tran Van Kiem, Tran Van Vu, Cao Minh Thong, Nguyen Thi Hong Hanh, Nguyen Thi Thuy Duong, Phan Trong Lan, Nguyen Hoang Long, Nguyen Thanh Long (2014) “The knowledge, behaviors about HIV/AIDS in the injecting drug users in Quang Nam province 2011”, Vietnam Journal of Preventive Medicine 4(153):99-105. 2. Tran Van Kiem, Tran Van Vu, Cao Minh Thong, Nguyen Thi Hong Hanh, Nguyen Thi Thuy Duong, Phan Trong Lan, Nguyen Hoang Long, Nguyen Thanh Long (2014), “Effective interventions to prevent transmission of HIV among injecting drug users in Quang Nam province”, Vietnam Journal of Preventive Medicine 4(153):106-111. INTRODUCTION HIV/AIDS pandemic was first recognized as a new disease in 1981 in the Unites State. Nowadays, the HIV/AIDS pandemic has become a global threat. According to the Joint United Nations Programme on HIV/AIDS, as of 2012, there were approximately 35.3 million people worldwide living with HIV/AIDS. There are about 2 million deaths annually. HIV/AIDS pandemic circulates mainly in the developing countries and causes directely economical, political, and social burden in many countries. In Vietnam, there were 216.254 people living with HIV in end of 2013,66.533 AIDS patients and 68.977 deaths due to AIDS. Due to not available cureandvaccines preventable for HIV/AIDS, many countries in the world have launched the strategic activities of prevention in order to limit the HIV transmission into the community. One of the main cause for HIV/AIDS transmission in Quang Nam provinve is the injecting drug users (IDUs) group accounted for more than 65% of HIV infection cases diagnosed annually with high-risk behaviors for HIV transmission and lack of knowledge on HIV prevention. Targeting these subjects will play an important role in reducing speed of the HIV/AIDS transmission. However, there has been no study describing in detail the high-risk behaviors of HIV transmission among IDUs and no effective intervention of HIV prevention for this group. Therefore, we conducted the study: 1. To identify the HIV prevalence and risk behavior for HIV transmission among IDUs in Quang Nam province in2011; and 2. To evaluate the effectiveness of intervention for HIV transmission prevention among IDUs in Quang Nam province, 2012-2013. New scientific contributions of the dissertation The HIV prevalence and risk behaviors for HIV transmission among IDUs have been identified in Quang Nam province, 2011. The effectiveness of the prevention intervention program for HIV transmission among IDUs was also evaluated in Quang Nam province, 2012-2013. The primary inplementation of preventive intervention of HIV transmission among IDUs has gained an effectiveness of HIV transmission prevention in Quang Nam province. The structure of the thesis The thesis consists of 134 pages including Introduction (3 pages), Chapter 1. Background (36 pages), Chapter 2. Objectives and Methods (21 pages), Chapter 3. Results (38 pages), Chapter 4. Discussions (33 pages), Conclusions (2 pages), and Recommendations (1 page). There are 28 tables, 30 figures, 1 diagram, and 124 references. CHAPTER 1 BACKGROUND 1.1. HIV/AIDS Epidemic Situation The first HIV patient was diagnosed in December 1990 in Ho Chi Minh City, Vietnam. There were 216.254 people living with HIV/AIDS in 2013, 66.533 AIDS patients and 68.977 deaths due to AIDS. According to the HIVsentinel surveillance in 2013, the HIV prevalence among IDUs was 10.3% , and much higher than female sexual workers groups (FSWs) (2.6%). Injecting drug plays a principal role in HIV transmission in Vietnam. Almost of the HIV cases in Quang Namwere IDUs (70%). There has been an increasing number of unemployed young adults and adolescents suffered from social evil including drug desire. The uncontrollablyincreasing number of HIV infection among IDUs may lead to high risk of HIV/AIDS outbreak in Quang Nam province. 1.2. Risk behaviors for HIV transmission among injection drug users Sharing syringes and needles when injecting drugs is the main reason of HIV transmission in many countries in the local region and worldwide. The HIV prevalence among IDUs is 5-10% in the world. However, thisprevalence in some regions in Asia and Europe are over 50%. In Vietnam, the injecting drug are different between urban area and rural area. In the last 15 years, sharing syringes and needles is common among IDUs. The percentage of sharing syringes and needles in the past six months among IDUs are 14-50%. The studies show that there are 87%IDUs sharing syringe and needle, in which 40% IDUs consistently sharing syringes and needles. Cleaning syringes and needles when injecting drugs are very casual and unsterilized. It is also risk factor for HIV transmission among IDUs. Other side, IDUs usually have other risk behaviors for HIV transmission, leading to increase expose probability of HIV transmission by having sex among IDUs and their sexual partners. The combination between drug injection and having sex with FSWs increase risk of HIV transmission. IDUs do not use condom frequently in having sex with FSWs and sexual partners is the important reason of HIV transmission. 1.3. Prevention intervention programs for HIV transmission 1.3.1. Communication program for behavior change Behavior change communication for HIV/AIDS is an approach in several levels to encourage and maintain the behavior change in order to reduce risk of HIV transmission for individual and community by broadcasting health messages through different channels of communication. 1.3.2.Condom use promotion program The foundation of this program includes effectively preventive solutions for HIV transmission with low cost. It was estimated that if 1000 condoms are bought and used, 03 HIV/AIDS cases will be prevented. The condom use promotion program has been implemented in many countries and proved to be effective. 1.3.3Needle and syringe exchange program The needle and syringe exchange program has been implemented in Europe since 1982. Until now, the program has been expanded worldwide and it is an important activity of harm reduction intervention to prevent HIV transmission for IDUs. 1.3.4. Substitution therapy with methadone program This program has been recognized as a high effectiveness in prevention of HIV transmission. Using oral methadone, drug users will reduce and stop using needle and syringe, leading to reduce risk of transmitting HIV. 1.3.5. HIV voluntary counselling and testing program HIV voluntary counselling and testing program is the start point for assessible services and HIV/AIDS prevention. According to international experiences, this program, which is one of important components in HIV/AIDS control, plays a role in both prevention and care for HIV/AIDS patients. CHAPTER 2 SUBJECTS AND STUDY METHODS 2.1. Subjects and settings 2.1.1. Study subjects  Subjects for cross-sectional study: men aged over 18, injected drug in the last month and living in community and voluntary participating study.  Subjects for the intervention trial: Injecting drug users aged over 18 living in family or community and voluntary participating study. Criteria for exclusion from the study: aged under 18, women, prisoner, person in center for education-social labor, person with mental disorder. 2.1.2. Study location: The study was conducted in five districts: Tam Ky, Phu Ninh, Thang Binh, Que Son, and Phuoc Son. 2.1.3. Study time: from October 2011 to Mar 2014. 2.2. Study methods 2.2.1. Study designs: Cross-sectional study, retrospective review, and community-based health intervention trial without control and with comparison between before and after intervention. - Cross-sectional study: Data were collected using direct interview of IDUs with a questionnaire. Blood sample of subjects was collected for HIV testing. *Sample size was calculated using the formula for estimating a proportion: p (1 – p) 2 n = Z (1-α/2) d2 n: minimum sample; α = 0.05, Z(1-α) = 1.96; d = 0.05; p= 0.37-prevalence of IDUs sharing syringe and needle in previous six months in Da Dang province. The calculated sample size was 359 subjects. A total of 430 subjects were recruited for the study. *Sample collection: Mapping locations where IDUs used drugs in 5 districts was performed to estimate the IDUs number in each district. The subject number for each district was proportionally assigned to the estimated number of IDUs in this district. Study communes were recruited using a simple random sampling method. - Community-based health intervention trial * Stepts for intervention: Firstly, developing plan for HIV transmission prevention. Next, selecting study site and implementing intervention. Lastly, supervision and evaluation were conducted after intervention. *Sample size was estimated using formula to compare two proportions in the intervention group: n: minimum sample; α = 0.05, Z(1-α) = 1.96; power = 0.9, Z(1-β) = 1.28; P1 was the percentage of IDUs sharing syringe and needle in the past six months before intervention (P1 = 0.335); P2 was the percentage of IDUs sharing syringe and needle in tthe pas six months after 2-year intervention (P2 = 0.235, 10% reduction); P = (P1 + P2)/2 = 0.285. Estimated sample size was 416 subjects. A total of 430 subjects were recruited for the intervention study. 2.2.4. Study content  Organizing meetings with local administrators, social organizer on preventive intervention of HIV transmission.  Building networks of volunteers, homologous groups to implement communication activities for behavior changes, condom delivery, and sterilized syringe exchange.  Implementing broadcasting programs and radio in levels of province, districts and communes. Delivery of materials.  Setting up communication for behavior changes in public areas.  Building sites for condom delivery, sterilized syringe exchanges in community, pharmacy, and commune health station.  Conducting activities of HIV counselling and testing for study subjects in the fixed location and mobile station in local areas.  Conducting surveys before and after intervention, mapping and selecting samples in community. 2.2.5. Data collection: Using a quantitative questionnaire in surveys before and after intervention. 2.2.6. Study indicators Based on the objectives of the study, the study indicators were divided into two groups with 16 indicators, including: HIV prevalence, proportion of sharing syringe, proportion of drug injection, proportion of condom use in sexual contact, proportione of always using condom when having sex with partners, proportion of obtaining HIV counselling, proportion of receiving communication on safe injection, proportion of receiving communication on safe sex, proportion of receiving sterilized syringe and needle, proportion of receiving free condom. 2.2.7. Materials HIV testing was performed in Quang Nam Center for HIV/AIDS Control and Provincial Center for Preventive Medicine in Quang Nam according to procedure III with biochemical approved by Vietnam Ministry of Health for use in Vietnam: Determine, Genscreen HIV -1/2 version 2, Vironostika Uniform II. 2.3. Data analysis: Data were entered, analyzed using softwares Epi Data, STATA and M. Excel. 2.5. Ethnical consideration The study was approved by local administration. Subjects were informed before the study and they freely participated in the study. CHAPTER 3 RESULTS 3.1. HIV Prevalence and risk behaviors for HIV transmission in the injection drug users in Quang Nam province, 2011 3.1.1. Risk behaviors for HIV transmission The study was conducted among 430 men in Quang Nam province in2011. Of the total subjects, Kinh group were 96.3%, 20-29 age group accounted for 52.8%, elementary education was 59.1%, and 54.4% had irregular jobs. Table 3.6. Duration of drug injection (n = 430) Duration < 1 year 1 - < 2 years 2 - < 3 years ≥ 3 years N 51 62 74 243 % 11.9 14.4 17.2 56.5 The duration of drug injection more than 3 years was highest (56.5%), followed by 2-3 year injection (17.2%), and drug injection under one year accounted for 11.9%. Table 3.7. Drug injection behaviors in previous month (n = 430) Content N 1. Frequency of drug injection (n = 430) ≥ 4 times/day 7 2 - 3 times/day 101 1 time/day 142 < 1 time/day 168 Don’t remember 12 2. Category of used drugs (n = 430) Heroin 376 Opium 42 Synthetic drugs 51 % 1.6 23.5 33.0 39.1 2.8 87.4 9.8 11.9 Drug injection less than 1 time/day accounted for the highest proportion (39.1%), followed by drug injection 1 time/day (33%), 2-3 times/day (23.5%), and more than 4 times/day (1.6%). Heroin accounted for 87.4% and synthetic drugs accounted for 11.9%. Not sharing syrines and needles: 66,5% Sharing syrines and needles: 33,5% Figure 3.4. The proportionof sharing syringes and needles in the past six months (n = 430) The proportion of sharing syringes and needles in the past six months was 33.5%. Percentage 21.2% 30% 20% 10% 0% Dùng chung Sharing BKT syrines and needles 19.5% Đưa BKT Sending used syrines and needles 18.4% Nhận BKT Receiving used syrines and needles Figure 3.5. The proportion of sharing syringes and needles in the past month (n = 430) The proportion of sharing syringes and needles in the past month was 21.2%, in which 19.5 % was giving used syringes and needles, and 18.4% was receiving used syringes and needles. Percentage 60% 36.1% 41.7% 40% 20% 13.9% 8.3% 0% Not Notđủ đủ Không ThíchLike dùng Không sharing enough enough tiền BKT chung money syrines Others Khác Figure 3.7. Reasons for sharing syringes within the past six months (n=144) The common reasons for sharing syringes were not enough syringes (41.7%), not enough money (36.1%), and like sharing (13.9%). Percentage 100% 80% 60% 40% 20% 0% 85.6% 7.2% SúcBy nước clean lạnh water SúcBy nước hot nóng water 10.3% Súc By cồn alcohol 4.5% Khác By others Figure 3.8. Manners of cleaning syringes and needles (n = 43) Clean water was the most frequently used to sterilized syringes (85.6%), followed by alcohol (10.3%) and by hot water (7.2%). Table 3.10. The proportion of condom use and having sex with female sexual workers Content N % 1 - 4 times 55 51.4 5- 9 times 29 27.1  10 times 23 21.5 Yes 71 66.4 No 36 33.6 1. Having sex in the past month (n = 107) 2. Using condom in the past month (n = 107) 3. Frequency of using condom when having sex in the past 12 months (n = 151) Always 39 25.8 Almost 60 39.7 Rarely 37 24.5 Never 15 9.9 The proportion of using condom in having sex with FSWs in the past month was 66.4%. The proportion of always using condom in having sex in the past 12 months was 25.8%, 39.7% for almost of times. There were 24.5% IDU using condom rarely and 9.9% never use condom. Table 3.11. The proportion of condom use and having sex with casual partner Content N % 1. having sex in the past month (n = 46) 1 - 4 times 39 84.8 5- 9 times 3 6.5 4 8.7 10 times 2. Using condom in the past month (n = 46) Yes 27 58.7 No 19 41.3 3. Frequency of using condom when thaving sex in the pas 12 months (n = 89) Always 5 5.6 Almost 21 23.6 Rarely 51 57.3 Never 12 13.5 The proportion of using condom in having sex with casual partners in the past month was 58.7%. The proportion of always using condom in having sex in the past 12 months was 5.6%, 23.6% for almost of times. There were 57.3% IDU using condom rarely and 13.5% never use condom. 3.1.2. HIV Prevalence among injection drug users in Quang Nam Non HIV infection: 93.7% HIV infection: 6.3% Figure 3.11.HIV prevalence among injection drug users in 2011 (n=430) The HIV testing results showed that the HIV prevalence among IDUs was 6.3% in Quang Nam province, 2011. 3.2. Effectiveness of prevention intervention for HIV transmission among injection drug users in Quang Nam province after two years of intervention 3.2.1. Effectiveness of HIV testing and counselling Percentage 100% 74.2% 88.2% Before… intervention Trước Sau canintervention thiệp After 25.8% 50% 1.8% 0% Required Được yêu cầu Voluntary Tự nguyện Figure 3.13. Effectiveness on HIV testing methods The proportion of IDUs had voluntary HIV testing increased from 74.2% before intervention to 88.2% after intervention (p < 0.01). Percentage 75.1% 80% 63.3% 60% 31.8% 40% Before intervention Trước can thiệp 40.2% After intervention Sau can thiệp 20% 0% Counselling Tư vấn trướcbefore xét nghiệm HIV testing Counselling Tư vấn sau xétafter nghiệm HIV testing Figure 3.14.Effectiveness of counselling before and after HIV testing The proportion of IDUs obtained counselling before HIV testing increased from 31.8% before intervention to 63.3% after intervention (p<0.01); the effective indicator (EI) was 99.1%. The proportion of IDUs obtained counselling after HIV testing increased from 40.2% before intervention to 75.1% after intervention (p<0.01, EI=86.8%). 3.2.2. Effectiveness of care and support for injection drug users Table 3.24. Effectiveness of communication for behavior changes (n = 430) Indicator Before intervention N % After intervention N % Effective indicator P Safe injection 64 14.9 252 58.6 293.8 0.0001 Safe sexual contact 121 28.1 310 72.1 156.2 0.0001 After 2-year intervention, the proportion of IDUs receiving communication on safe injection in the past six months increased from 14.9% to 58.6% (p<0.01, EI=293.8%). The proportion of receiving communication on safe sex increased from 28.1% to 72.1% (p<0.01, EI=156.2%). Percentage 60% 40% 20% 0% 58.2% 19.8% Before Trước can thiệp intervention Sau After can thiệp intervention Figure 3.15. The proportion of injection drug users receiving free condom After intervention, the proportion of IDUs receiving free condom in the past six months increased from 19.8% to 58.2% (p < 0.01, EI=193.9%). Percentage 40% 30% 20% 10% 0% 32.3% 1.4% Trước Before can thiệp intervention Sau After can thiệp intervention Figure 3.17. The proportion of injection drug users receiving sterilized syringes and needles The proportion of IDUs receiving sterilized syringes and needles in the past six months increased from 1.4% to 32.2% (p<0.05, EI=2207%). 3.2.3. Effectiveness of accessible services for HIV prevention Percentage 75.6% 82.3% 100% 80% 40.9% 38.4% 60% 40% 1.4% 2.5% 20% 0% Collaborator Đồng đẳng Cộng Hiệu thuốc Homologous tác viên Pharmacy partner viên Trước thiệp Beforecan intervention Sau canintervention thiệp After Figure 3.20. The proportion of injection drug users know place to buy/receive sterilized condom After intervention, the proportion of IDUs know place to buy/receive sterilized condom from peer educator and collaborator increased from 1.4% to 38.4% and from 2.5% to 40.9%, respectively. Table 3.27. The proportion of injection drug users know place to buy/receive sterilized condom (n=430) Before After Effective intervention intervention indicators (%) N % N % 392 91.2 401 93.3 2.3 58 13.5 112 26.0 93.1 76 17.7 137 31.9 80.3 122 28.4 154 35.8 26.2 Pharmacy Peer educator Collaborator Health officer p 0.1247 <0.0001 <0.0001 0.01 After intervention, the proportion of IDUs know place to buy/receive sterilized condom from peer educarors increased from 13.5% to 26% (p<0.01, EI=93.1%), from collaborator increased from 17.7% to 31.9% (p<0.01, EI= 80.3%). 3.2.4. Effectiveness on changes of risk behaviors Percentage 6% 5.6% 3.3% 4% 2% 0% Trước Before can thiệp intervention After Sau can thiệp intervention Figure3.22. The proportion of sharing syringes and needles in the last injection The proportion of sharing syringes and needles in the last injection decreased from 5.6% before intervention to 3.3% after intervention (p > 0.05). Percentage 30% 21.2% 13.7% 20% 10% 0% Trước can thiệp Before intervention Sau After can thiệp intervention Figure 3.23. The proportion of sharing syringes and needles in the past month (n = 430) After intervention, the proportion of sharing syringes and needles in the past month decreased from 21.2% to 13.7% (p<0.01, EI=35.2%). Percentage 40.0% 30.0% 20.0% 10.0% 0.0% 33.5% 22.6% Trước Before can thiệp intervention Sau can thiệp After intervention Figure3.24. The proportion of sharing syringes and needles in the past six months (n = 430) The proportion of sharing syringes and needles in the past six months decreased significantly from 33.5% (before intervention) to 22.6% (after intervention) (p<0.01, EI=32.6%). Percentage 71.4% 80.0% 60.0% 40.0% 20.0% 0.0% 41.7% TrướcBefore can thiệp Sau can thiệp After intervention intervention Figure 3.25. The proportion of cleaning syringes and needles After intervention, the proportion of cleaning syringes and needles increased from 41.7% to 71.4% (p<0.05, EI=71.4%). Percentage 100.0% 87.8% 65.4% 75.0% 54.3% 50.0% Trước can thiệp Before Before intervention intervention Sau canintervention thiệp After After intervention 0.0% Phụ nữ mại dâm Female sexual worker Bạn tình bất Accidental chợt partner Figure 3.27. The proportion of using condom with sexual partner The proportion of using condom with FSWs in the ast time increased from 65.4% (before intervention) to 87.8% (after intervention) (p<0.01, EI=: 34.1%). This proportion with casual partner increased from 54.3% (before intervention) to 75% (after intervention), (p < 0.05, EI=38.0%). Percentage 86.1% 100% 65.6% 80% 60% 40% 20% Before intervention Trước can thiệp After intervention Sau can thiệp 56.1% 29.2% 13.3% 15.6% 0% Vớifriend Với phụ nữ Với bạn tình Female sexual Accidental Wife/girl vợ/người mạiworker dâm bất chợt partner yêu Figure 3.28. The proportion of injection drug users always using condom in the past 12 months After 2-year intervention, the proportion of IDUs always using condom when having sex with female sexual worker in the past 12 months increased from 65.6% to 86.1% (p<0.01, EI=31.3%). This proportion when having sex with casual partner increased from 29.2% to 56.1% (p<0.01, EI=92.2%). 3.2.5. HIV Prevalence among the injection drug users before and after intervention Percentage 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 6.3% 4.4% Trước Before can thiệp intervention Sau can thiệp After intervention Figure 3.29. HIV Prevalence among injection drug users before and after intervention (n = 430) After 2-year, interventive solutions for HIV transmission in IDUs could contribute partly to decreasing HIV prevalence in the study. The HIV prevalence among IDUs decreased from 6.3% (before intervention) to 4.4% (after intervention) (p<0.05, EI=29.6%). CHAPTER 4 DISCUSSION 4.1. HIV Prevalence and risk behaviors for HIV transmission among injection drug users in Quang Nam province 4.1.1.Risk behaviors for HIV transmission The results of the survey in 2011 showed that the duration of drug injection of IDUs was not long time in this study. Drug injection over 2 years accounted for 73.7%, and drug injection less than 2 years was 26.3%. Our results were much lower than those in other provinces: durations of drug injection over 2 years were 82.5% in Dong Thap province, 94.5% in Kien Giang province, and 96.4% in Lai Chau province. Through the survey, we have recorgnized that many young men have just sufferd from drug injection; they were unemployed, like imitating others and strange sensation. We called them as “Amateur group”. This group has high risk of HIV transmission because they had not only drug injection but also strongly when having sex. Some studies indicate that IDUs have a strong sexual desire caused by narcotics at the beginings. However, sexual need reduces significantly after 1.5-2 years later and it is replaced by a desire for using narcotics. Some people lose sexual desire. Therefore, in the first period of the 2-year drug injection with strong sexual desire, they have a risk of double HIV transmission among them and between them and other sexual partners. Of the drugs used by injection drug users, heroin accounted for the highest proportion (87.4%), followed by synthetic drugs (11.9%), and opium (9.8%), indicating that heroin was the most common used among them. The results showed that the proportion of IDUs sharing syringes and needles in the past 6 months was common (33.5%). The proportion of sharing syringes and needles in the past month was 21.2%, in which 19.5 % was giving used syringes and needles, and 18.4% receiving used syringes and needles. Reasons lead to sharing syringes and needles were not enough money, low HIV knowledge, discrimination of their family and society toward IDUs let them have sneaky injection. To satisfy the drug addiction, they were willing to use syringes and needles of their partners or reuse unsterlized syringes and needles. In the present study, the proportion of IDUs sharing syringes and needles in the past six months was lower than that in Da Nam (37.2%), Lao Cai (35.3%) and higher than that in the 10 provinces of the 2009 IBBS survey: Nghe An (28.3%), Dong Nai (27.1%), Yen Bai (25.1%), Ho Chi Minh City (24.6%)… This is a very dangerous behavior and it make HIV easy to transmit among injection drug users. The proportion of IDUs not using condom with FSWs and casual partners 33.6% and 41.3%, respectively. Different to wife/girlfriend, using actively condom when having sex with FSWs was mainly decided by injection drug users. That the IDUs play an active role in drug injection shows a good sign for improving behavior using condom in sexual contact. However, relative low proportion of always using condom when having sex with FSWs and casual was 65.5% and 29.2%, respectively. This indicates the high risk of HIV transmission from IDUs to FSWs, casual partner, and among them due to unsafe sexual. 4.1.2. HIV prevalence among injection drug users HIV prevalence among IDUs was 6.3% at baseline survey in 2011. This prevalence is much lower than that in whole country in 2011 (13.4%) and many provinces in South and North of Vietnam. This prevalence is higher than that in neighbouring provinces in the same region. For instance, the HIV prevalence among IDUs was 1% in Da Nang according to the second round of IBBS survey in 2009. In 2010, Tran Kim Phung reported the HIV prevalence among IDUs was 3.9% in Quang Tri. Results from current supervision in Quang Nam showed very high HIV prevalence among IDUs, which accounted for 65.8% of the total HIV infection cases detected within the last 5 years. The present study also reflects that the real status of HIV transmission pathways in Vietnam is mainly done through IDUs with data from intensive supervision from 1996 to 2014. 4.2. Effectiveness of prevention for HIV transmission among injection drug users in Quang Nam 4.2.1. Effectiveness of counselling and HIV testing The study showed that the proportion of IDUs had voluntary HIV testing increased from 74.2% to 88.2% after 2-year intervention (p < 0.01). The proportion of IDUs received counselling before HIV testing increased from 31.8% before intervention to 63.3% after intervention (p<0.01); the effective indicator was 99.1%. The proportion of IDUs received counselling after HIV testing increased from 40.2% before intervention to 75.1% after intervention (p<0.01); the effective indicator was 86.8%. After 2-year intervention, voluntary counselling and testing for HIV has been changed significantly. Studies on cost and home-based voluntary counselling and testing for HIV in several countries have a conclusion that home-based voluntary counselling and testing for HIV is a important component in the strategy of care and prevention of HIV/AIDS in countries. 4.2.2. Effectiveness of care and support for injection drug users After 2-year intervention, the proportion of receving communication on safe injection in the past six months increased from 14.9% in 2011 to 58.6% in 2014 (p<0.01), and its effective indicator was 293.8%; the proportion of receiving communication on safe sex increased from 28.1% in 2011 to 72.1% in
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