1. Factors Associated with Methadone Maintenance Enrollment among Opioid Injecting Users and in Vietnam: A Case-Control Study Nguyen Nguyen 1, Onyebuchi Arah 2 and Roger Detels 2 1 National Institute of Hygiene and Epidemiology, Vietnam 2 Department of Epidemiology, University of California, Los Angeles Presenting author: Nguyen Nguyen, nguyenucla@gmail.com

2. The Vietnam MMT Program: Some activities...

3. Presentation outline Introduction Research Necessity and Objective Study sites Methods Results and Discussion Implications/Recommendations

4. INTRODUCTION: The Pilot Methadone Maintenance Treatment (MMT) Program in Vietnam MMT: worldwide use for decades; multiple proven benefits. 2008-2009 MMT pilot project in Hai Phong & HCMC, 3 clinics in each province, 250 patients per clinic. High level of attention and dedicated resources from many sectors (health, public security, international organizations, mass organizations, etc). Patients carefully selected via a multi-step reviewing process with strict admission criteria.

5. Integrated psycho-social counseling service; high average methadone dose (~110mg/day) High retention: 90% after 1 year; 80% after 2 years Low concurrent drug use: 10% at 1 year; injecting frequency is greatly reduced All clinics full to capacity (or beyond) April 2010: National expansion plan aiming at enrolling 80,000 DUs in 30 provinces by 2015 May 2013: 60 MMT clinics are operating in 20 provinces with ~13,000 patients on methadone INTRODUCTION: The Pilot MMT Program in Vietnam (continued)

6. Research necessity and objective Results of the pilot MMT program => National scale- up will probably be beneficial, but: –Initial results were from a small fraction of drug users who had been carefully selected =>non-representative. –The pilot program was carried out in somewhat special conditions. Identification of barriers and facilitators of enrollment is needed to target groups that are less likely to enroll and enhance service utilization in future. Study objective: To identify factors associated with MMT enrollment among opioid IDUs in Hai Phong, Vietnam.

7. STUDY SITES Hai Phong: 2 urban (urban) districts & 2 rural (less urbanized) districts randomly selected from the 4 urban & 3 rural districts where MMT clinics were operating in early 2011. Urban and rural districts were included as two separate strata because socio-economic characteristics and other MMT-related conditions were anticipated to be different between them.

8. Why study in Hai Phong? The province with the most MMT clinics in Vietnam (7 clinics when this study started in 2011). Among top 3 provinces with the highest number of PLHIV in recent years: HCMC, Ha Noi and Hai Phong. Population size (1.9 million) and work-related migration are less than those of Hanoi and HCMC.

9. Map of Hai Phong and location of the 4 selected districts Thuy Nguyen An Lao Hong Bang Le Chan

10. Study design: Case-control study Participants: An injecting drug user (IDU) was defined as a person who had used opoid(s) in at least 25 out of a 30-day period in the past, mainly by injection.  Case definition: A case was an IDU who had registered for MMT in previous 6 months.  Control definition: A control was a current IDU who had never registered for MMT. Exclusion criteria: Under 18yrs old; severely ill; clear signs of opioid withdrawal or poor behaviors, “trainees” of ‘06 centers. METHODS

11. Sample size and participant selection: – 150 cases recruited anonymously via MMT clinics, local health workers and peer educators, 35-40 cases from each of the 4 districts. – 446 controls selected from 600 participants of the concurrent survey who had never registered for MMT. The survey recruited current IDUs anonymously via pharmacies and N&S programs. Data collection technique: ACASI Data analysis: Conditional logistic regression stratifying on district of residence (SAS 9.2) was used to derive odds ratios. Twenty-one predictors variables included in the initial regression model; 9 variables with P-value > 0.2 remained in the final model. METHODS (continued)

12. RESULTS Factors OR (95%CI) P-value Gender (female vs. male) 0.26 (0.05-1.25) 0.09 Marital status Never married vs. married 1.06 (0.65-1.75) 0.80 Separated/divorced/widowed vs. married 1.99 (1.12-3.54) 0.02 Family care (all members except small children care deeply vs. other situations) 1.93 (1.25-2.98) 0.003 Receiving regular allowance from family/relatives (yes vs. no) 1.97 (1.29-3.02) 0.002 Length of injecting opioid use (every 5-year increment) 1.31 (1.04-1.65) 0.02 Number of injection per day (every additional injection/day) 1.34 (1.08-1.66) 0.008 Number of past drug cessation attempts (every additional attempt) 1.11 (1.05-1.18) <0.001 Past history of HIV testing (yes vs. no) 4.78 (2.52-9.04) <0.001 One-way travel time to MMT clinic (every additional 10 minutes) 0.80 (0.66-0.98) 0.03

13. This study was conducted in a context characterized by high demand, limited access to MMT and existence of multiple administrative and logistic barriers. Results from this study are supported by those from the related qualitative and cross-sectional studies: – Family care and financial support were important facilitators of MMT enrollment. – Longer history of injecting use, higher daily injection frequency, and more drug cessation attempts in the past were positive predictors of MMT registration (but # of times attending 06 centers was not). – Travel time from home to MMT clinic and female gender were negative predictors of MMT enrollment Why problematic marriage and past history of HIV testing were associated with MMT registration? DISCUSSION

14. Implications/Recommendations for the MMT program in Vietnam a)The potential barriers to MMT enrollment identified in this study need be further examined and addressed, i.e., how to improve enrollment among: Female IDUs? Those who live far from MMT clinics? New IDUs? b)The supportive role of family (emotional, logistical, financial,…) should be enhanced.

15. THANK FOR YOUR ATTENTION! The study of which results are presented herein is part of a research project implemented with financial support from the U.S. NIH via the UCLA/Fogarty AIDS International Training and Research Program (AITRP), organizational support from the Vietnam National Institute of Hygiene and Epidemiology, local health agencies and drug-user peer groups in the study districts in Hai Phong,Vietnam. Dr. Nguyen (the presenting author) was a PhD student Fellow of the Vietnam Education Foundation and a trainee in the UCLA/Fogarty AITRP during the time this study was conducted. Acknowledgment