1. Community Attitudes Toward Harm Reduction for Injection Drug Users (IDUs): Evidence from a Cross-Border HIV Prevention Project in Ning Ming County (Guangxi Province), China and Lang Son Province, Vietnam Theodore M. Hammett, Ph.D., Abt Associates Inc., Cambridge, MA, USA Giulia D. Norton, M.P.H., Abt Associates Inc. Ryan Kling, M.A., Abt Associates Inc. Wei Liu, M.D., Guangxi Center for HIV/AIDS Prevention and Control, Nanning, China Yi Chen, M.D., Guangxi Center for HIV/AIDS Prevention and Control Doan Ngu, M.D., Hanoi, Vietnam Kieu Thanh Binh, M.D., Hanoi, Vietnam Ha Viet Dong, M.D., Hanoi, Vietnam Don C. Des Jarlais, Ph.D., Beth Israel Medical Center, New York City, NY, USA Abstract TuOrC1113 XV International AIDS Conference, Bangkok July 13, 2004

2. Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project XV International AIDS Conference, Bangkok July 13, 2004 2 Funding Support National Institute on Drug Abuse, Grant No. DA-14703 – Research Ford Foundation (Beijing and Hanoi) – Interventions Address for Correspondence: Theodore M. Hammett, Ph.D. Abt Associates Inc. 55 Wheeler Street Cambridge, MA 02138 USA ted_hammett@abtassociates.com

3. Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project XV International AIDS Conference, Bangkok July 13, 2004 3 Background First-ever cross-border HIV prevention project (with interventions on both sides) targeting IDUs Drug Trans-shipment Routes Heroin Use Heroin Injection HIV Transmission Increasing HIV Prevalence Cross-Border Transmission Other Cross-Border Movement –Small-scale movement across long, porous border –Trade, migratory employment, floating population –Intermarriage, ethnic minority groups on both sides

4. Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project XV International AIDS Conference, Bangkok July 13, 2004 4 Geographic Setting China Vietnam Hanoi Area of Detail Large Project Site Small Border Site Key: Vietnam China Ning Ming City Lang Son City Puzhai Tan Thanh Dong Dang Loc Binh Tongmia n Shilang Aidian Hop Thanh CaoLoc Town Ha Giang Guigang PDI Site Map of Project Sites

5. Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project XV International AIDS Conference, Bangkok July 13, 2004 5 Peer-based education of IDUs (outreach model in original sites) Peer-Driven Intervention (PDI) in two new sites: Ha Giang, Vietnam, and Guigang, China Public health: collection/safe disposal of used needles/syringes Social marketing of new needles/syringes direct distribution and through redemption of pharmacy vouchers Community education Full implementation of interventions in original sites began July (Vietnam) – October (China), 2002 Intervention

6. Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project XV International AIDS Conference, Bangkok July 13, 2004 6 Methods – Pre- and multiple-post intervention follow-up Cross-sectional surveys of IDUs baseline + 6, 12, 18, 24, 30 months; Baseline, 6- and 12-month completed in China and Vietnam HIV testing (with counseling) Capture-recapture component HIV incidence estimation, longitudinal behavior change – KAP surveys in community (HIV knowledge, knowledge of/attitudes toward project) same intervals as IDU surveys – Process data Peer educator logs (contacts, collection of used needles/syringes) Pharmacy/clinic logs (vouchers redeemed) Evaluation

7. Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project XV International AIDS Conference, Bangkok July 13, 2004 7 HIV Knowledge in the Community Correct AnswersChinaVietnam Knowledge of HIVBaseline (n = 321) % 12 Months (n = 307) % p-valueBaseline (n = 250) % 12 Months (n = 250) % p-value Transmitted through needle sharing 92.888.7.0799.697.9.10 Not transmitted by touching/hugging an HIV+ person 75.186.4.000289.887.2.03 Not transmitted through eating with HIV+ person 55.570.8<.000179.384.4.23 Cannot tell HIV+ from appearance 55.173.4<.000173.257.4.0006 Can prevent HIV by not sharing needles 57.952.3.1462.569.9.08 Can prevent HIV by using condoms 58.970.5.00294.389.0.07

8. Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project XV International AIDS Conference, Bangkok July 13, 2004 8 Baseline levels of HIV knowledge were generally higher in Vietnam and showed more improvement in China. Continued community education is necessary to overcome persistent misinformation and related stigmatization. Community Knowledge of HIV/AIDS

9. Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project XV International AIDS Conference, Bangkok July 13, 2004 9 Community Attitudes toward the Interventions Correct AnswersChinaVietnam Attitudes toward Interventions Baseline (n = 321) % 12 Months (n = 307) % p-valueBaseline (n = 250) % 12 Months (n = 250) % p-value Will reduce discarded needles/syringes 57.357.5.9696.898.0.61 Will reduce spread of HIV 75.476.0.8596.898.7.37 Will not increase drug use 62.367.9.1371.468.7.69

10. Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project XV International AIDS Conference, Bangkok July 13, 2004 10 Baseline attitudes toward the interventions were more positive in Vietnam but attitudes changed little at 12 months Community generally believes that the intervention will reduce HIV spread (12-month results on HIV prevalence and incidence) Community education is needed to dispel the common misunderstanding that the intervention will lead to increased drug use In fact, obtaining larger numbers of pharmacy vouchers (Vietnam) or new needles/ syringes directly (China) from the project was not associated with increased frequency of heroin injection (Ning Ming: p =.38; Lang Son: p =.57) Community Attitudes toward the Interventions

11. Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project XV International AIDS Conference, Bangkok July 13, 2004 11 HIV Prevalence in Each Site VietnamBaseline (n = 348) 6-Month (n = 350) 12-Month (n = 327) Lang Son Cao Loc Loc Binh Dong Dang Tan Thanh All Lang Son Sites 57% 42% 41% 40% 5% 46% 53% 34% 42% 14% 46% 49% 43% 34% 35% 27% 43% ChinaBaseline (n = 308) 6-Month (n = 343) 12-Month (n = 307) Aidian Tongmian Shilang Ning Ming City All Ning Ming Sites 32% 63% 25% 12% 17% 38% 44% 29% 18% 23% 19% 55% 23% 9% 14%

12. Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project XV International AIDS Conference, Bangkok July 13, 2004 12 Based on matched ID numbers in cross-sectional IDU surveys Limitations – Numbers are very small (n = 38 susceptibles in Lang Son and n = 72 in Ning Ming, China – Potentially missed matches due to some participants giving false information for ID numbers (e.g., Ning Ming at 12 months 36% said they had participated in a previous survey, but only 21% of records could be matched by ID numbers). Estimated annual incidence among IDUs – Lang Son (12 months, 3 seroconversions, 2 in first 6 months, 1 between baseline and 12 months): 12.8% (95% CI: 2.5 – 64.2 ) – Ning Ming (12 months, 2 seroconversions, both between baseline and 12 months): 4.5% (95% CI: 1.0 – 20.9) – Note: Very wide confidence intervals Stable prevalence is likely to be maintained with 4 –8 % annual incidence, because of attrition (e.g., deaths due to HIV/AIDS or drug overdose) Estimated HIV Incidence Among IDUs

13. Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project XV International AIDS Conference, Bangkok July 13, 2004 13 HIV transmission has not been halted, but... HIV incidence appears to be going down: Lang Son baseline 18%, 12 months 13%; Ning Ming baseline 7%, 12 months 5% (Note: Different method used for baseline calculation: HIV-positives who reported injecting 5 years were assumed to have been infected midway through self-reported injecting history) Data from subsequent followup surveys should improve the precision of the incidence estimates Comments Regarding HIV Incidence

14. Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project XV International AIDS Conference, Bangkok July 13, 2004 14 This is a path-breaking project, offering very important opportunities to control a cross-border HIV epidemic and increase cross-border collaboration. The interventions are generally acceptable to pharmacies, IDUs, police, and the general community. Continued and increased attention is needed to stigmatization of drug use and IDUs. Ongoing community education and regular meetings with all stakeholders are essential to maintain support and understanding. HIV Prevalence is stable through 12-month followup. HIV transmission has not been halted but incidence but may be coming down. Further evidence of the effectiveness of the interventions awaits subsequent followup IDU and community surveys. Conclusions

15. Community Attitudes Toward Harm Reduction for IDUs: China-Vietnam Cross-Border Project XV International AIDS Conference, Bangkok July 13, 2004 15