Harm Reduction Strategies in HIV Prevention among Injection Drug Users in Vietnam
In 2010, the HIV epidemic is expected to shift in intensity from Sub-Saharan Africa to Asia, with Injection Drug Users (IDUs) playing a central role in the rapid growth of HIV prevalence (Hammett). Drug use in Vietnam started growing during the USA-Vietnam War, but intensified after the economic liberalization of the late 1980s and 1990s (Thanh). In 2007, UNAIDS estimated 290,000 people living with HIV in Vietnam, with a 45.2 prevalence of HIV among IDUs in major urban areas and a 23.7 prevalence outside of urban areas[1] (UNAIDS Epi). HIV IDUs make up the largest proportion of HIV cases reported in Vietnam (Thanh), and this population is a central risk factor in the spread of the epidemic. Efforts in HIV prevention among IDUs have been slow and continue to face many cultural, social and political barriers. However, HIV transmission among IDU populations has reduced since adapting harm reduction policies such as Needle Syringe Programs (NSP), Peer Educators, and Opioid Substitution Treatments (OST) (Hammett).
RISK BEHAVIORS
IDUs are at high risk of HIV transmission in Vietnam due to unsafe injection practices. While studies indicate that sharing injection equipment has decreased over the past few years (Thanh), over 30% of IDUs reported sharing syringes in Hanoi (Pankonin). In addition to equipment sharing, the reuse of equipment and leftover drugs are pivotal in HIV transmission. Shooting galleries––discrete locations where drugs are sold and injected––are associated with high risk behavior as they support an increased likelihood of equipment sharing, less access to safe injecting equipment, and limited access to clean rinse-water or a clean injecting environment (Hien). Other risk factors for HIV transmission include receiving injections from drug dealers, injecting on the streets and sharing drug pots (Hien).
SOCIAL, CULTURAL AND POLITICAL RESISTANCE
Drug use carries huge social and cultural stigmas in Vietnam, and drug users are widely considered a “social evil” (Hammett). IDUs and people living with HIV often face discrimination, isolation, and fear of rejection. One qualitative study highlighted four common HIV-related fears and stigmas shared by people living with HIV: personal feelings of shame, behavior changes directed towards people living with HIV, a stigmas regarding HIV transmission, and general stigma attached to being associated with a person living with HIV. These stigmas and fears are harmful to individuals, families, and communities, and discourage people from seeking testing and treatment (Gaudine).
The possession, sale and use of drugs are illegal in Vietnam; those who are found in violation of these laws face strict punishments including forced detoxification, mass arrest, and incarcerations (Hammett). Recognized injection locations are often raided by law enforcement, and IDUs have developed quick and unsafe routines for drug use in order to avoid arrest, including discarding injection equipment in public areas (Pankonin). Fear of being arrested is a barrier to IDUs seeking safer injection practices. Despite the availability of safe injecting equipment through needle-syringe programs, IDUs remain reluctant to carry needles because of fear of being arrested, putting pressure on IDUs to get drugs and equipment from dealers or to participate in high risk needle sharing or reuse (Thanh). Harm reduction as a priority response for HIV prevention among IDUs was slow to start in Vietnam due to law enforcement and police resistance, a lack of political support, and unsafe practices. However, the implementation of harm reduction into Vietnam’s cultural, social, and political responses to IDUs plays a pivotal role in HIV prevention.
TRANSITION TO HARM REDUCTION: THE BENEFITS
Although equipment sharing has been a major avenue for HIV transmission in Vietnam since the early 1990s, it wasn’t until 2004 that harm reduction was incorporated into the National Strategy for HIV Prevention and Control (Ngo), which supported Needle Syringe Programs (NSP), 100% condom-use, and Peer Educators, but excluded opioid substitutions (Hammett). In January 2007, The National HIV/AIDS Law of 2006 and Decree 108/2008 finally incorporated not only harm reduction as an HIV prevention method into law, but also included opioid substitution as a harm reduction method (Thanh; Hammett).
Although they remain highly controversial, harm reduction interventions have all shown positive reductions in HIV transmission in IDU communities (Hammett). Harm reduction interventions have begun to shift much of the association of Needle-Syringe Programs away from drug prohibition and enforcement, which act as barriers for successful NSP programs, towards the idea of reducing harm that accompanies drug use. Such a transition incorporates not only drug users but also the general population in HIV prevention by spreading awareness and confronting stigmas associated with HIV and IDU (Wodak Lessons).
Evidence from international reviews of the effect of harm reduction program in HIV prevention found it to fit into six of the nine Bradford Hill criteria[2] and five extended criteria[3], further supporting the positive impact of these programs in HIV intervention in Vietnam (Wodak). Needle Syringe Programs used by IDUs was found to be protective for seroconversion and seropositivitiy outcomes, to improve primary health care of IDUs[4], and to offer education regarding infectious disease transmission and protection practices valuable in HIV prevention (Wodak).
Peer Educators often work through Needle Syringe Programs in outreach programs organized by peer educator clubs and health services (Ngo). Peer Educator programs include counseling, the distribution, collection and clean up of injection equipment, health education and condom promotion (Thanh). Additional benefits of peer educators are in practicing advocacy to reduce HIV and IDU stigma and discrimination and encouraging communities to see IDUs and people living with HIV not as ‘social evils’ but as patients. Peer educators also conduct training programs for government officials and law enforcement in the benefits of harm reduction strategies (Hammett, Ngo).
TRANSITION TO HARM REDUCTION: THE BARRIERS
Although sharing injection equipment and HIV prevalence has declined among IDUs in Vietnam since harm reduction initiatives were first introduced, high-risk practices remain prevalent. Stigma and discrimination remain widespread, and although resources are available, they are often limited and difficult to access through health services (Wodak Lessons, WHO). While Vietnam has taken great strides forward in HIV prevention, including the addition of harm reduction methods into law, many barriers such as stigma, discrimination, and strict law enforcement, continue to impede these programs and people’s willingness to incorporate risk reduction practices into their routine (Hammett).
CONCLUSION
Internationally, harm reduction programs have proven to be safe and effective in HIV reduction among IDUs (Wodak). Vietnam has taken many pivotal steps to reduce HIV transmission by approving Needle Syringe Programs, methadone substitution treatment, and peer educators for IDUs, and has established AIDS centers in 90% of provinces (UNAIDS country). Because of the high prevalence of HIV in IDUs, there is a great risk of transmission to other by sharing needles and sex. Therefore, harm reduction methods for IDUs will continue to be crucial in the prevention of HIV in Vietnam.
References
- Gaudine, A., Gien, L. Thuan, T., Dung, D. Perspectives of HIV-Related Stigma in a Community in Vietnam: A Qualitative Study. Int. J. of Nursing Studies. 2001, 47: 38-48
- Hammett, T.M., Wu, Z., Duc, T.T., Stephens, D., Sullivan S., Liu, W., Chen, Y., Ngu, D., Des Jaflai, D.C. ‘Social Evils’ and Harm Reduction: The Evolving Policy Environment for Human Immunodeficiency Virus Prevention Among Injection Drug Users in China and Vietnam. Addiction. 2007, 103: 137-145.
- Hien, N., Giang, L., Binh, P., Devillé, W., Ameijden, E., Wolffers, I. Risk Factors of HIV Infection and Needle Sharing Among Injection Drug Users in Ho Chi Minh City, Vietnam. J. of Substance Abuse. 2001, 13 : 45-58
- Ngo, A.D., Schmich, L., Higgs, P., Fischer, A. Qualitative Evaluation of Peer-Based Needle Syringe Programme in Vietnam. Int. J. of Drug Policy. 2009, 20: 179-182.
- Pankonin, C.A., Higgs, P., Reid, G., Aitken, C. Selling Syringes to Injecting Drug Users: A Study of Five Pharmacies in Hanoi, Vietnam. J. Infect Developing Countries. 2008, 2 (1): 51-58.
- Thanh, D.C., Moland, K.M., Fylkesnes, K. The Context of HIV Risk Behaviours Among HIV-Positive Injection Drug Users in Viet Nam: Moving Toward Effective Harm Reduction. BMC Public Health. 2009, 9 (98): 1-9.
- UNAIDS Vietnam. Country Situation. July 2008.
- UNAIDS Vietnam. Epidemiological Fact Sheet on HIV and AIDS: Core Data on Epidemiology and Response. December 2008.
- Wodak, A., Cooney, A. Do Needle Syringe Program Reduce HIV Infection Among Injection Drug Users: A Comprehensive Review of the International Evidence. Substance Use & Misuse. 2006, 41: 777-813
10. Wodak, A. Lessons From the First International Review of the Evidence for Needle Syringe Programs: The Band Still Plays On. Substance Use & Misuse. 2006, 41: 837-839.
11. World Health Organization. Viet Nam: Summary Country Profile for HIV/AIDS Treatment Scale-Up. December 2005.
[1] These figures are the median prevalence taken from the maximum and minimum estimates of HIV prevalence of a given population (UNAIDS Epi).
[2] The six Bradford Hill criteria fulfilled by NSP: Strength of Association, Replication of Findings, Temporal Sequence, Biological Plausibility, Reasoning by Analogy, and Coherence of Evidence (Wodak).
[3] The five extended criteria: Cost-Effectiveness, Absence of Negative Consequences, Feasibility of Implementation, Expansion and Coverage, Unanticipated Benefits, and Application to Special Populations (Wodak).
[4] Primary Health care includes but is not limited to drug treatment and reduction of infectious diseases (Wodak).
