SUBSANCE USE DISORDERS AND HIV THREE DECADES AFTER Doi Moi : AN OVERVIEW

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1 SUBSANCE USE DISORDERS AND HIV THREE DECADES AFTER Doi Moi : AN OVERVIEW LE MINH GIANG Center for Research and Training on HIV/AIDS (CREATA) Vietnam-HIV Addiction Technology Transfer Center (VHATTC) Hanoi Medical University, Vietnam October 2, 2015 ATHS 12, Biarritz, France 1

2 ANRS Acknowledgement Organizing Committee of ATHS 12 R03 DA (PI: Le Minh Giang, A-START) R01 DA (PI: Korthuis) R24 HD (PI: Hirsch and Parker) V- HEART (Viet Nam HIV testing and Early initiation of ART among IDUs) Research Team (funded by WHO) Economic Evaluation of MMT and CCT Research Team (funded by Atlantic Philanthropies) All of you who have inspired and supported HIV and SUD research and programs in Vietnam Colleagues at CREATA, Hanoi Medical University 2

3 Key contents The triple epidemics of injection drug use, HIV and Hep C Overview of HIV epidemic, especially among IDUs Preliminary knowledge on HCV epidemic among IDUs Overlapping of risks among key populations National responses and key challenges Rapid expansion of both MMT and ART services Key challenges in making integrated services accessible to IDUs Key challenges for social support, especially the CBOs and the family 3

4 Triple Epidemics 4

5 Number (Estimate) A stable epidemic by national indicators PLHIV [Estimate] AIDS related deaths [Estimate] New HIV infections [Estimate] Source: Prepared by based on UNAIDS. (2014). UNAIDS HIV Estimates and

6 Concentrated among key populations Key population size estimates and HIV prevalence Population Size Estimates (2013) HIV prevalence (2014) Injecting Drug Users (IDU) 271, Female Sex Workers (FSW) Men Who Have Sex With Men (MSM) 71, , Source: Prepared by based on Viet Nam Global AIDS Response Progress Reporting 2014

7 HIV prevalence among key populations, NCMT PNBD MSM 35,0 30,0 29,3 29,3 28,6 25,0 20,0 15,0 10,0 5,0 0,0 17,3 14,9 10,9 0,6 1,0 0,7 1,5 13,4 2,4 16,6 20,5 3,8 3,5 23,9 4,7 5,9 3,8 22,7 4,4 3,5 25,6 23,1 20,2 4,2 3,9 3,1 20,3 18,4 17,2 3,5 4,6 13,4 4,0 11,6 3,6 10,7 2,9 2,6 2, ' 01' 02' 03' 04' 05' 06' 07' 08' 09' 10' 11' 12' 13' 14' 6,7 10,5 2,5 Source: VAAC

8 Geography of HIV Prevalence Source: VAAC

9 HIV prevalence among IDUs in three IBSSs 100 Ha Noi HCMC 75 65,8 Hai Phong % 58,7 55,7 Can Tho ,0 23,9 48,0 46,1 20,7 39,1 40,1 23,3 23,8 An Giang Quang Ninh Dien Bien Nghe An Yen Bai Sources: IBBS 2005, 2009 and 2013

10 HCV prevalence since the first injection (2006) Source: Clatts et al. (2009) 10

11 Prevalence of HBV and HCV infection among high risk groups in 2009 IDU MSM SSW VSW Mean HBs Ag (+) Median IQR HBs Ag (-) & Anti-HBC (+) Mean Median IQR HCV Ag/Ab (+) Mean n/a n/a Median n/a n/a IQR n/a n/a Source: IBBS Results

12 Prevalence of Hepatitis B and C Viruses and HIV Co-Infection among HIV patients, Vietnam The prevalence of HBV, HCV or both with HIV co-infection is 50.3%. Among these: HBV/HIV: 8.4% HCV/HIV: 35.4% HBV/HCV/HIV: 6.5% Huy BV et al 2014

13 Overlapping risk behaviors: Proportion of MSM and FSW who have ever injected drugs, % MSM FSW 0 Bac Giang Can Tho Ha Noi Thai Binh Thanh Hoa HCMC An Giang Source: Prepared by based on Viet Nam Administration of HIV/AIDS Control (VAAC) Report on the results of HIV sentinel surveillance plus among high-risk groups in Viet Nam in 2012

14 Drug use among MSM (IBBS and Hanoi surveys) Drug Use in Past 30 Days among MSM 2 30% 27,10% 25% 22,20% Proportion of MSM who reported ever having used and injected drugs, % 25% 20% Ever used drugs 19,8% Ever injected drug 20% 15% 10% 5% 0% Estasy 10,40% Methamphetamine 7,80% 2,40% 4% Ketamine Cocaine Heroin Any drug 15% 13,2% 13,1% 10% 5% 0% 5,3% 1,5% 1,6% 2,6% Can Tho HCMC Ha noi Hai Phong 1. MOH IBBS Round III, Courtesy of Nguyen BD (2013)

15 Drug use and HIV epidemic among FSWs HIV prevalence was greater among FSW who reported lifetime illicit drug use, including injection compared to those who had never used illicit drug L-V.N Le et al, Drug Alcohol Depend

16 Risk behaviors of female sex partners (FSPs) of male injection drug users (MIDUs) in HCMC MIDUs: 50% HIV positive; FSPs: 35% HIV positive Using illegal drugs among FSPs: 60.3% reported ever using illegal drugs 72.7 % reported ever injecting illicit drugs Risk factors: FSPs reporting injection drug for 1 year were more likely to be infected HIV [adjusted Odds Ratio (aor 2.94; 95% CI ); FSPs were at increased odds for being HIV+ if they had male IDU partner infected with HIV [(aor 3.35; 95% CI ) Nadol et al (2015) 16

17 Alcohol consumption among IDUs Go et al 2012

18 Drinking and sexual risks among MSM (Hanoi) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Drinking Level by AUDIT Score among MSM Low-risk Hazardous Harmful Dependence 1.4% 22.2% 74.5% 19.3% 21.2% 23.1% 15.3% 41.4% 16.2% 34.5% 29.0% 1 2 Men VN MSM Hanoi MSW Kenya 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Alcohol Drinking Level (AUDIT) by Condom Use among MSM 7.1% 23.3% 18.7% 24.5% 42.9% 41.0% 31.3% 11.2% Consistent Inconsistent Low-risk Hazardous Harmful Dependence Courtesy of Nguyen BD (2013) 1 Giang KB, Subst Use Misuse 2008; 43: 3 2 Luchters S, BMC Public Health 2011, 11: 384

19 Responses and Key Challenges 19

20 Substantial progress since Doi Moi Phát hiện ca đầu tiên nhiễm HIV ở VN Chính phủ ra Nghị quyết 20/CP về đẩy mạng công tác phòng, chốn g HIV/AIDS Trường ĐHYHN ra quyết định thành Lập Trung tâm Nghiên cứu và Đào tạo HIV/AIDS 61 tỉnh thành phát hiện người nhiễm HIV CDC cam kết hỗ trợ VN phòng chống HIV Thành lập Cục PC HIV/AIDS Bắt đầu mở rộng chương trình điều trị HIV (ARV) tại Việt Nam Luật phòng, ch ống HIV/AIDS chính thức có hiệu lực Thí điểm điều trị Methadone Trưng bày 20 năm HIV/AIDS ở Việt Nam VN khởi động chương trình Mục tiêu

21 Number of patients Number of OST tises Rapidly expanding MMT sites and patients Number of patients Number of OST sites Source: Prepared by based on National Committee for AIDS, Drug and Prostitution Prevention and Control. (2014). Vietnam AIDS Response Progress Report, Following Up the 2011 Political Declaration on HIV/AIDS. Reporting period: January 2012 December 2013

22 Comparing outcomes of MMT patients (n = 384) and CCT returnees (n = 208) over 12 months

23 Emerging methamphetamine use in Vietnam UNODC (2013)

24 MMT-HIV-ART Cascade Estimated: 217,000 Recorded: 171, Centers Drug Users 25-35, MMT Clinics MMT Retention: Haiphong 1 Year 90% 2 Years 80% 13,000 HIV- Negative 77.5% Data Source: VAAC 2012 Methadone Maintenance 0 HIV+ 22.5% 13,000 2,925 ARV 71.4% IDU's MMT ART Courtesy of Gary West (2013)

25 MMT enrollment among ART-initiated HIV+ IDUs Receiving MMT at baseline Receiving MMT at 6 months Thai Nguyen (N=122) Thanh Hoa (N=136) 54 (44.3%) 67 (54.9%) 33 (24.3%) 41 (30.2%) Total (N=258) 87 (33.7%) 108 (41.9%) One third of participants accessing MMT at baseline; uptake of MMT increased after study enrolment

26 Number of people on ART % ART coverage Rapid scale up of ART access ( ) NOTE: ART coverage (%) represents the proportion of people receiving ART out of the total number of people living with HIV Estimated ART coverage Number of people on ART Source: Prepared by

27 Người Vietnam HIV cascade of care by gender (2013) % Nữ Nam % % 38% Estimated PLHIV Diagnosed PLHIV Registered with OPCs Receiving ART 99% 99% Nguồn: D28 - Cục PC HIV/AIDS,

28 IDU vs. non-idu Initiating ART in Vietnam IDU Non-IDU CD4 count < % 32.3% WHO stage III/IV 82.7% 68.4% TB 16.2% 10.0% HCV 52.6% 18.1% Alive & retained on ART 12 months 24 months 36 months 48 months 81.5% 73.6% 67.4% 63.3% Nguyen DB et al (2013) data from % 88.2% 88.2% 85.7%

29 Low proportion of key populations who are aware of their status % 100 Proportion of key populations who received an HIV test in the last 12 months and know their results, FSW MSM PWID Source: Prepared by

30 Cascades of HIV+ IDUs initiating ART at different CD4 levels 88% 86% 99% 89% Those starting ART with CD4 >350 cells/mm 3 had as good retention and viral suppression as those starting with CD4 350 cells/mm 3 39 had specimens collected for VL tests at month 6, but VL not yet analysed.

31 USD AIDS spending by financing source, $ $ $ $ Total AIDS spending Bilateral Global Funding Domestic Funding Source: Prepared by based on

32 NUMBER OF NEEDLES/SYRINGES Number of needle/syringes distributed per person who inject drugs per year, High coverage: >200 syringes per PWID per year Medium coverage: >100 < syringes per PWID per year Low coverage: <100 syringes per PWID per year Source: Prepared by based on 1. WHO, UNAIDS, & UNICEF. (2009). Towards Universal Access: Scaling up Priority HIV/AIDS Interventions in the Health Sector- Progress Report 2009; 2. WHO, UNAIDS, & UNICEF. (2010). Towards Universal Access: Scaling up Priority HIV/AIDS Interventions in the Health Sector - Progress Report 2010; 3. WHO, UNAIDS, & UNICEF. (2011). Global HIV/AIDS Response Epidemic Update and Health Sector Progress towards Universal Access Progress Report 2011; 4. National Committee for AIDS, Drug and Prostitution Prevention and Control. (2012). Vietnam Global AIDS Response Progress Report, 2012; 5. UNAIDS. (2013). Global Report: UNAIDS Report on the Global AIDS Epidemic 2013; and 6.

33 Years of establishment by types of CBOs (278 CBOs from 24 provinces surveyed in 2015) 33

34 Changes in budget by types of CBOs (compared to previous year) 100% 80% % 25 40% % 19 0% SW NCH IDU MSM PSP Khác 1 Tang Giam Khong thay doi 34

35 Financial burden of health care for HIV/AIDS patients The total cost of ART treatment per patient per year was US$611 (75% covered by state and donor, 25% from outof-pockets) % (95% CI = ) of households would be affected if ART were not subsidized 1 Source: 1. B.X Tran et al 2013; 2.Nguyen LT et al

36 Costs for MMT treatment million Vietnam dong = US$ 640 Source: Vuong T.H, PhD thesis

37 Caregiver burden perceived by IDU s Family members S.-J. Lee et al, AIDS care,