MINISTRY OF EDUCATION AND TRAINING
MINISTRY OF NATIONAL DEFENCE
MILATARY MEDICAL UNIVERSITY
NGUYEN HUYNH
SITUATION OF HIV INFECTION, RISK BEHAVIOURS
OF INFECTION AMONG INJECTING DRUG USERS AND
FFECTIVENESS OF COMPREHENSIVE INTERVENTION MODEL IN
THREE PROVINCES: HOA BINH, BAC KAN AND TUYEN QUANG
Major: Hygiene, Sociology and Health Administration
Code: 62.72.01.64
SUMMARY OF PHD THESIS
HANOI – 2018
THIS STUDY
UNIVERSITY
WAS
COMPETED
AT
MILATARY
MEDICAL
Scientific supervisor:
1. Prof. Nguyen Thanh Long
2. Assoc.Prof Nguyen Van Hung
Reviewer 1: ………………………………………………………….
.………………………………………………………….
Reviewer 2: ………………………………………………………….
………………………………………………………….
Reviewer 3: ………………………………………………………….
………………………………………………………….
Thesis will be defended in University Council meeting at Military Medical
University
At……., day……, month,…..year
Thesis can be found at:
1. National Library
2. Library of Military Medical University
3. ………………………….
1
BACKGROUND
By the end of 2009, Vietnam has experienced nearly 20 years
of the HIV/AIDS epidemic and HIV/AIDS prevention and control
has achieved some encouraging results. However, HIV/AIDS still
remains the most dangerous infectious disease. As of December 31,
2009, there were 201,034 people living with HIV in Vietnam [1].
HIV epidemic in Vietnam was in the “concentrated epidemic”
period that was extremely complicated, stabalized in some big
provinces and cities and tend to increased in some northern
mountainous provinces including Hoa Binh, Bac Kan and Tuyen
Quang provinces with high incidence of HIV infection and drug use.
Comprehensive intervention model had been proposed. Thus, we
conducted the study “Situation of HIV infection, risk behaviours of
infection among injecting drug users and effectiveness of
comprehensive intervention model in three provinces: Hoa Binh, Bac
Kan, Tuyen Quang” to evaluate the effectiveness of the model. The
objectives were:
1. To describe the situation of HIV infection and risk
behaviours of infection among injecting drug user in three provinces:
Hoa Binh, Bac Kan, Tuyen Quang (2009-2010).
2. To evaluate the effectiveness of comprehensive intervention
model to prevent HIV transmission among injecting drug users
(2011-2013).
Practical values of the thesis
The prevalence of HIV infection in the three provinces
(29.1%), percentage of needle-sharing in the last month was 30.8%
and in the last 6 months was 46.2%. The needle – sharing behaviour
2
in the last 1 month and last 6 months associated with prevalence of
HIV infection with OR and CI as follows: (OR 3.07; CI95%: 1.785.31) and (OR 2.73; CI95%: 1.56-4.76) with statistical significance,
p<0.05.
The needle – sharing behaviour in the last 1 month and last 6
months after intervention decreased from 30,8% to 18,4% with
p<0,05, effectiveness index of 40,26%; from 46,2% to 24,5% with
p<0,05, effectiveness index of 47,0% respectively. The prevalence of
HIV decreased from 29,1% to 18,8%, p<0,05.
Participants with more engagement in the intervention showed
more change in risk behaviours, for example, those who with 3
intervention measures showed no decrease in needle-sharing practice,
but those who with 5 measures or more showed more decrease of
needle-sharing with p<0.05.
Structure of thesis: the thesis consists of 125 pages (33 tables, 14
graphs and 3 figures), including 4 chapters: Background: 2 pages;
Chapter 1 Literature review: 34 pages; Chapter 2 Study participants
and methodology: 18 pages; Chapter 3 Study results: 37 pages;
Chapter
4
Discussion:
31
pages;
Conclusion:
2
pages;
Recommendation: 1 page. Reference: 121 documents including 55
Vietnamese language and 66 foreign language.
Chapter 1 LITERATURE REVIEW
1.1. Definition and concepts
HIV stands for Human Immunodeficiency Virus indicating a
kind of virus causing the acquired human immunodeficiency
syndrome. Once invading the human body, HIV would gradually
destroy the immune system that disables the ability of body to fight
with diseases.
3
HIV transmission prevention intervention: is a policy and
program aiming at preventing HIV/AIDS and other infectious disease
transmission for high risk groups.
1.2. Situation of drug use, HIV/AIDS in the world and in
Vietnam
According to UNODC in 2017, the total number of drug users
around the world was approximately 255 million, aged between 1564 years [9], [10]. In Vietnam, up to the end of 2014, there were
204,377 drug users, of which 2156 drug users were reported in Hoa
Binh, while it was 1475 users in Bac Kan and 1155 users in Tuyen
Quang [28], [29], [30]. The global number of injecting drug user
(IDU) was 12.19 million, among those 1.65 million people (0.92-4.42
million) were living with HIV, accounting for 13.5% IDUs.
The report of UNAIDS showed that there were about 36.7
million living with HIV, the estimated prevalence was 0.8% of global
population aged 15-49 years [14], [15]. In Vietnam, updated to 31
December 2017, the cummulative number of people living with HIV
was 209,452 people, the number of AIDS patients were 90,105 and
the number of deaths were 94,622 cases. Up to the end of 2014, the
number of people living with HIV in Hoa Binh, Bac Kan and Tuyen
Quang were 2117, 2402 and 2067 respectively.
1.3. The comprehensive intervention for IDUs
Though the HIV/AIDS epidemic has emerged long time ago,
there has not been specific treatment and vaccine to prevent HIV
infection due to its complexity. Thus, the prevention measures have
been still considered as the most important.
According to the decision number 608/QĐ-TTg dated
25/5/2012 of Prime Miniter to approve the Proposal of HIV
4
transmission prevention under the National Strategy on HIV/AIDS
prevention and control to 2020 and with vision to 2030, there are
intervention measures for drug users including communication to
change behaviour, distribution of needle, condom; substance abuse
treatment by replacement therapy; HIV voluntary counseling and
testing [38, [39].
Chapter 2 STUDY PARTICIPANTS AND METHODOLOGY
2.1. Study participants, materials, sites and time
2.2.1 Quantitative study participants
- Drug users living in study sites.
- Project staff, health workers, members of peer-counselor
group, sex workers using drug, people living in study sites…
Inclusion criteria:
- Above 18 year old
Drug users with at least once in the last 30 days from the
investigation date.
- There was no serious health problem that can influence the
participation in 30 minutes of interview.
- Agree to participate in the study.
Exclusion criteria for drug users:
-
Below 18 years old
-
Broke the agreement in informed consent form, showed
dangerous behaviours, interupted the result interpretation.
2.1.2. Qualitative study participants
-
Drug users living in study sites.
-
Project staff participating ”project of HIV/AIDS Asia region
in Vietnam” in local and centre
5
-
Members of peer-counselor group, sex workers using drug,
-
People above 18 year old living in study sites in 6 months of
study time
2.1.3.
Study materials:
-
Reports of relevant organizations.
2.2. Study sites
Study was conducted in 3 provinces, 2 districts/quaters per
provinces were selected as follows: Hoa Binh (Hoa Binh city and
Mai Chau district), Bac Kan (Bac Kan town and Cho Moi district)
and Tuyen Quang (Tuyen Quang city and Son Duong district)
2.3. Study time
Total time for the study was separated in 2 phases:
- Phase 1: Situational study (2009-2010).
- Phase 2: Interventional study (from 01/2011 - 12/2013).
2.4. Study methodology
Interventional study with pre- and post-intervention evaluation
and without control (by two descriptive cross-sectional studies)
2.5. Sample size
The sample size before and after the intervention was
calculated for each province with the similar formula as follows:
n=
[ Z 1−α √ 2 p ( 1− p)+ Z1−β √ p 1( 1− p1 )+ p2 ( 1− p 2) ]
2
Of
( p 2 −p 1 )2
which:
p1 = prevalence of needle-sharing among injecting drug users
in the last 6 months in previous survey in Hoa Binh (0.475), Bac Kan
(0.434) and Tuyen Quang (0.416).
6
p2 = estimated prevalence in the next investigation in Hoa Binh
(0.338), Bac Kan (0.297) and Tuyen Quang (0.279).
p=(p1+p2)/2;
Z1-α = 1,96; Z1-β= 0,84.
The actual sample size for pre-intervention study was 608
people, of which 201 people from Hoa Binh, 200 people from Bac
Kan and 207 people from Tuyen Quang.
The actual sample size for post-intervention study was 601
people, among those 200 people from Hoa Binh, 201 people from
Bac Kan and 200 people from Tuyen Quang.
2.6. Sample selection
“Date-site” sample selection (VDTs) developed by US CDC.
2.7. The indicators
2.2.7.1. Indicators for situational study
- Some socio-demographic characteristics, occupation and
income;
- Drug use behaviour;
- Risk behaviours;
- HIV transmission among drug users and associated factors.
2.2.7.2. The indicators for evaluating the outcomes and effectiveness
of the comprehensive intervention model
- The coverage of comprehensive intervention model
- The prevalence of HIV infection and risk behaviours after
intervention
- Evaluation of the effectiveness of
comprehensive
intervention model.
2.8 The model of comprehensive intervention
The comprehensive intervention model, included:
7
- Communication to change behaviours;
- Provision of clean needle and syringe; collection of used
needle and syringe;
- Condom distribution;
- Voluntary counseling and testing, free HIV testing for the
participants;
- Implementation of substance abuse treatment by Methdaone
replacement therapy.
2.9. Data collection
2.9.1. Quantitative study data collection method
2.9.2. Qualitative study data collection method
2.10. Laboratory testing
HIV testing was conducted with algorithm III of Ministry of
Health [5].
2.11. Study implementation
The author is a member of the study who has got permission of
Asia regional HIV/AIDS prevention and control project in Vietnam
and principle investigator to use the data for this thesis.
2.12. Data management and analysis
The data was entered and analysed by SPSS version 18.0, Stata
version 12.0 with statistical tests.
2.13. Ethical issues
We implied with the ethical principles: totally voluntary
participation of the subjects. Obtaining informed consent form for
each participant. Study was approved by IRB committe of National
Institute of Hygiene and Epidemiology prior to implemtation.
8
Chapter 3 STUDY RESULTS
3.1. Situation of HIV infection and risk factors of transmission
among drug users in three provinces: Hoa Binh, Bac Kan, Tuyen
Quang (2009-2010)
3.1.1. Socio-demographic characteristics of the drug users
The mean age of drug users in the three provinces was 34.3
years, mostly in the group of 30-39 years old (49.7%), which was
47.3% in Hoa Binh, 47.5% in Bac Kan and 54.1% in Tuyen Quang.
Almost all the participants are male (97.4%), female (2.6%).
32.1% of participants were ethnic minorities, among the three
provinces, Bac Kan had the highest percentage of ethnic minorities
(54%), followed by Hoa Binh (35.8%) and Tuyen Quang with 7.2%.
The percentage of drug users living with wife/husband in three
provinces was 58.6%. The figure was 67.1% in Tuyen Quang, 59.0%
in Bac Kan and only 49.3% in Hoa Binh.
Few participants were illiterated (0.8%). The education level of
secondary school accounted for the highest percentage (49.9%) for
all three provinces, which was 42.8% in Hoa Binh, 46% in Bac Kan
and 60.3% in Tuyen Quang. Approximately 3.8% of drug users in
three provinces completed college or university level, Hoa Binh is
10%.
58% of drug users in Bac Kan were manual workers and
13.5% unemployed while the 34% of participants in Hoa Binh and
only 11.1% in Tuyen Quang were unemployed.
3.1.2. Drug use behaviours
Most of the participants initiated using drug after 20 years of
age, the mean age was 23.5 years. The mean duration of drug use was
6.3 years.
9
Those who with 1-3 drug shots per day accounted for the
highest percentage with 58.8%, which was 93%, 52.9% and 31.6%
for Hoa Binh, Bac Kan and Tuyen Quang, respectively.
The majority of drug users in three provinces had withdrawed
several times (78%), the figure was similar in three provinces.
Heroin was the most popular drug with 96.7% in all provinces,
which was highest in Hoa Binh (99.7%), Bac Kan (98.5%) and Tuyen
Quang (92.3%), ATS was rarely used in 3 provinces with 2.6%.
The most common mode was injecting drug use (93.9%),
inhaling (14.1%) and other mode was 3.6%.
3.1.3. High risk behaviours
100Sharing needle and syringe in the last 1
month
80
%
60
40
20
0
Hoa Binh (n=187)
Bac KanTuyen
(n=189)
Quang (n=195)
All (n=571)
10
Figure 3.3. Needle and syringe sharing behaviour
The percentage of drug users reused needle/syringe in the three
provinces in the last 1 month was 30.8%, while it was 46.2% in the
last 6 months. The behaviour of sharing needle/syringe in the last 6
months was highest in Hoa Binh with 54.5%, followed by Bac Kan
with 43.9% and Tuyen Quang with 40.5%.
68.4% of participants had sexual intercourse in the last 1 month,
97.1% in Tuyen Quang, 65.0% in Bac Kan and 42.3% in Hoa Binh.
49.8% had sex with wife/husband, 21.1% with sex workers;
18.4% with regular sexual and 10.4% with irregular sexual
partners.The highest having sex with wife/husband was in Tuyen
Quang (66.7%), Bac Kan (53.5%) and Hoa Binh (28.9%).The
percentage of having sex with sex workers was in Tuyen Quang
(28.5%), Bac Kan (21.5%) and Hoa Binh (12.9%).
Condom use was common with irregular partners (73%) but
not common when they have sex with sex workers (37.5%).
3.1.4. HIV transmission among drug users
11
42
40
30
29.1
25.9
19.8
20
%
10
0
H
oa
nh
Bi
20
=
(n
1)
Ba
c
K
an
20
=
(n
ye
u
T
0)
n
Q
ng
ua
20
=
(n
7)
A
ll
60
=
(n
8)
Figure 3.6. Prevalence of HIV infection among drug users
The prevalence of HIV infection among drug users in three
provinces was 29.1%, which was 42% in Bac Kan, 25.9% in Hoa
Binh and 19.8% in Tuyen Quang.
Table 3.17. Association between HIV infection and risk factors
12
Bivariate
Multivariate
OR[95% CI] p value OR[95%CI] p value
HIV prevalence
<0.05
13.17
[1.78– 97.32]
Being IDU
Duration of being IDU
>0.05
0.87
(less than 3 years versus
[0.51– 1.47]
from 3 years and above)
<0.05
Sharing needle/syringe
6.33
in the last 1 month
[4.27– 9.39]
Sharing needle/syringe
6.14
in the last 6 month
[4.11– 9.18]
<0.05
Sharing other injecting
1.34
equipment
[0.94– 1.92]
>0.05
Have
sex
wife/husband
Have sex
workers
with
with
sex
<0.05
3.07
[1.78–5.31]
2.73
[1.56–4.76]
<0.05
<0.05
<0.05
0.66
0.65
[0.46– 0.93]
[0.43–0.97]
<0.05
0.52
[0.33– 0.84]
Do not use condom
>0.05
0.84
when having sex with
[0.49– 1.44]
wife/husband
Do not use condom
>0.05
0.92
when having sex with
[0.36– 2.32]
sex workers
0.65
[0.38-1.11]
>0.05
13
The bivariate logistic regression showed that 5 behaviours
including injecting drug use, needle/syringe sharing in the last 1
month, in the last 6 months before the investiagation date, have sex
with wife/husband and have sex with sex workers significantly
associated with HIV prevalence, p<0.05.
The multivariate logistic regression indicated 2 behaviour
including sharing needle/syringe in the last 1 month and in the last 6
months were in conducive to the increased risk of HIV transmission
with OR, CI as follows: (OR 3.07; CI95%: 1.78-5.31) and (OR 2.73;
CI95%: 1.56-4.76) with statistical significance p<0.05. Whereas, the
behaviour of having sex with wife/husband helped decrease the risk
of HIV infection (OR 0.65; CI 95%: 0.38-1.11) with statistical
significance p<0.05, the behaviour of having sex with sex workers
was confounder with p>0.05.
3.2. Evaluation of effectiveness of comprehensive intervention
model (2011-2013)
3.2.1. Evaluation of the coverage of comprehensive intervention
model
More than 90% of drug users were able to access the
communication materials on safe injecting drug use and safe sex.
The percentage of drug users joined the discussion with peer
counselors in the last 6 months was 77.7% for all three provinces,
which was highest in Bac Kan (83.1%), then Hoa Binh (82.1%) and
Tuyen Quang (68%). 97.3% drug users were provided clean needle
and syringe in the last 6 months, the figure for condom provision was
76.9%.
92% of drug users knew the health care settings where they
could find the HIV testing. 74.4% were tested in the last 3 years and
14
aware of their HIV status; only 49.4% were tested in the last 6
months. Bac Kan was 70.1%, Hoa Binh (61%) and Tuyen Quang
(15.5%).
86.2% of participants knew about the MMT program, but just
53% had visited MMT points, MMT registration was only 35.5%.
The figure for MMT ongoing treatment was very low with 26.8%.
Many people including drug users in the community agreed and
supported this program and expected more drug user to be engaged in
the program.
%
120
Used to receive at least one measure
Received at least 1 measure in the last 6 months
Received 3 measures
100
Received 5 measures
Received
all measures
80
60
40
20
0
Hoa Binh (n=200)
Bac Kan (n=201)
Tuyen Quang (n=200)
All (n=601)
Figure 3.11. Cascade model on comprehensive intervention
Almost 100% of drug users used to receive at least 1
intervention measure. Fairly high percentage of drug users received 3
measures (76.7%), or 5 measures with 57.6%. The percentage of drug
15
users received all measures was 18.5% while it was 31.5% and
23.9% in Hoa Binh and Bac Kan, respectively.
Before After
%
45
40
35
30
25
20
15
10
5
0
Hoa Binh
Bac Kan Tuyen Quang
All
3.2.2. HIV prevalence and risk behaviours among drug users
Figure 3.12. HIV prevalence before and after intervention
HIV prevalence in Hoa Binh, Bac Kan and Tuyen Quang after
3 years of comprehensive intervention measures was 12.5%, 25.4%
and 18.0%, respectively. The general prevalence in 3 provinces was
18.8%, compared with 29.1% before the implementation of
intervention measures.
HIV prevalence among drug users in 3 provinces after 3 years
of intervention has reduced from 29.1% to 18.8%, the difference was
statistically significant with p<0.05 and effectiveness index was
35.4%.
16
Table 3.18. Comparation of HIV prevalence
before and after intervention
HIV
prevalence
Before
After
n
(+)
%
608
177
29,1
596
112
EI
p
35,4%
<0,05
18,8
HIV prevalence of drug users in 3 provinces after 3 years of
intervention has decreased from 29,1% to 18,8%, with statistical
significance, p<0,05 and effectiveness index 35,4%.
Table 3.21.Comparison of sharing needle and syringe in the last 1
month
Risk behaviour
n
(+)
%
EI
Before
571
176
30.8
40.26
After
599
110
18.4
%
p
<0.05
The behaviour of sharing needle and syringe in the last 1
month of drug users in 3 provinces after 3 years of comprehensive
intervention model has declined from 30.8% to 18.4% with statistical
significance, p<0.05 and effectiveness index of 40.26%.
17
Table 3.22. Comparison of sharing needle and syringe in the last
6 month
Risk behaviour
n
Share
needle
%
Before
571
264
46.2
After
600
147
24.5
EI
p
47.0%
<0.05
Similarly, the behaviour of sharing needle and syringe in the
last 6 months of drug users in 3 study sites after 3 years of
intervention has reduced from 46.2% to 24.5% with statistical
significance, p<0.05 and effectiveness index of 47.0%.
Table 3.23. The percentage of not using condom when
having sex with sex workers
Risk behaviour
n
Do not use
condom
%
Before
128
80
62.5
After
36
14
38.9
EI
p
37.76%
<0.05
The percentage of not using condom in the last time of having
sex with female sex workers after years has declined from 62.5% to
38.9% with statistical significance, p<0.05 and effectiveness index of
37.76%.
- Xem thêm -
.DOCX 
29 
97 
132 
