Cross-Border Dimensions of HIV Transmission and HIV Prevention Among IDUs in Ning Ming County...

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


OverviewOverview

Geographic Setting

Cross-Border Dimensions of Drug Use and HIV Transmission

Cross-Border HIV Prevention Project


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


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


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


Guangxi Province, China: HIV spreads along drug trans-Guangxi Province, China: HIV spreads along drug trans-shipment routesshipment routes


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


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


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


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


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)



3.3. Trade and EmploymentTrade and Employment Legitimate business/commercial activity

Migratory labor

“Floating Population” – 1 million in area



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.


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


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)


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


Pharmacy/Clinic Voucher Pharmacy/Clinic Voucher – Lang Son Province– Lang Son Province


Pharmacy/Clinic Voucher Pharmacy/Clinic Voucher – Lang Son Province– Lang Son Province


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)


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


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

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Cross-Border Dimensions of HIV Transmission and HIV Prevention Among IDUs in Ning Ming County...

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