1. Cross-Border Dimensions of HIV Transmission and HIV Prevention Among IDUs in Ning Ming County (Guangxi Province), China and Lang Son Province, Vietnam Theodore M. Hammett, Ph.D., Abt Associates Inc., Cambridge, MA USA Cambridge, MA USA Don C. Des Jarlais, Ph.D., Beth Israel Medical Center, New York City, NY USA Center, New York City, NY USA Liu, Wei, M.D., Guangxi Center for HIV/AIDS Prevention and Control, Nanning, China Prevention and Control, Nanning, China Doan Ngu, M.D., National AIDS Standing Bureau, Hanoi, Vietnam Hanoi, Vietnam Nguyen Duy Tung, M.D., National AIDS Standing Bureau, Hanoi, Vietnam Bureau, Hanoi, Vietnam July 9, 2002

2. 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 Support National Institute on Drug Abuse, U.S. National Institutes of Health – Research Ford Foundation (Beijing and Hanoi) – Interventions

3. 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 Overview Geographic Setting Cross-Border Dimensions of Drug Use and HIV Transmission Cross-Border HIV Prevention Project

4. 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 Setting China Vietnam China Vietnam Hanoi Area of Detail Ning Ming City Langson town Puzhai Tan Thanh Dong Dang Loc Binh Tongmian Shilang Aidian Large Project Site Small Border Site Key: Map of Project Sites Hop Thanh CaoLoc Town

5. 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 Dimensions 1.Drug Trafficking  Drug Use  HIV Transmission Drug Trans-shipment Routes Golden Triangle  Vietnam  S. China  Hong Kong  The World Source: Beyrer et al., AIDS 2000; 14:75-83

6. 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 Use  HIV Transmission 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

7. 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- shipment routes

8. 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- shipment routes 21% HIV prevalence among IDUs in Pingxiang (adjacent to Ning Ming), ~10% in Ning Ming (awaiting Cross-Border project baseline survey – July 2002)21% HIV prevalence among IDUs in Pingxiang (adjacent to Ning Ming), ~10% in Ning Ming (awaiting Cross-Border project baseline survey – July 2002) Source: Guangxi Center for HIV/AIDS Prevention and Control

9. 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 along border with Guangxi Quang Ninh Province –  65% HIV prevalence among IDUs (Sentinel Surveillance, 2000) Lang Son Province – increasing numbers of cases

10. 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 along border with Guangxi Lang Son: ~80% of HIV cases are IDUs, ~21% HIV prevalence among IDUs (Sentinel Surveillance, 2000) – but concern about sampling makes figure uncertain. Awaits Cross-Border project baseline survey – July 2002Lang Son: ~80% of HIV cases are IDUs, ~21% HIV prevalence among IDUs (Sentinel Surveillance, 2000) – but concern about sampling makes figure uncertain. Awaits Cross-Border project baseline survey – July 2002 HIV Prevalence Among IDUs in Lang Son, 1996-2001 Source: Preventive Medicine Center of Lang Son, December, 2001

11. 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 Dimensions 2.Small-scale movement associated with heroin purchase/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

12. 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 Small.) Small-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)

13. 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 Dimensions 3.Trade and Employment Legitimate business/commercial activity Migratory labor “Floating Population” –  1 million in area

14. 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 Dimensions 4.Ethnic/Family Ties Common ethnic minority groups on both sides of border (e.g., Zhuang) Intermarriage common, although illegal and results in loss of nationality.

15. 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 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

16. 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 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)

17. 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.) 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

18. 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 – Lang Son Province

19. 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 – Lang Son Province

20. 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 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)

21. 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.) 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

22. 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 Conclusions 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