Stopping HIV at the Border:
An Innovative Project Targets Drug Users in China and Vietnam
In a remote mountainous region where
northern Vietnam meets southern China,
the heroin trade flourishes. As drug users
and dealers move fluidly across the border,
they carry not only heroin but the virus that
causes AIDS, infecting along the way other
users, sex partners, their children, and,
eventually, the community at large.
The infection spreads fastest among those
who share needles, but eventually moves
into non-drug-using populations, notes Ted
Hammett, a researcher for Abt Associates
who helped initiate an innovative needle
exchange and education program in this
region of heavy drug trafficking. In fact,
according to UNAIDS, widespread HIV
infection among injection drug users (IDUs)
typically precedes "large and sustained
HIV epidemics" in the general population.
Hammett, and his colleague Don Des
Jarlais, a prominent researcher at New
York's Beth Israel Medical Center, realized
several years ago that both China and
Vietnam could be on track for large-scale
epidemics when surveys reported that
more than 70 percent of HIV infections in
China and 60 percent in Vietnam were
found among IDUs.
It's the first-ever cross-border
HIV prevention program for
drug users offering the same
interventions on both sides of
the border.
In a project requiring an intricate and
politically sensitive collaboration among
Chinese and Vietnamese health officials,
police, pharmacists, and drug users,
Hammett and Des Jarlais in 2002
launched the first-ever cross-border HIV
prevention program for drug users offering
the same interventions on both sides of the
border. Hammett recently presented
preliminary results of the project, based in
China's Guangxi Province and Vietnam's
Lang Son Province, at the XV International
AIDS Conference in Bangkok, Thailand.
"It required four years of planning and
negotiation, but results have been
promising," Hammett notes. "Twelve-month
follow-up data suggest that the
intervention has been successful in
stabilizing HIV prevalence and transmission
on both sides of the border."
Translation of pharmacy voucher used in Lang Son Province, Vietnam
Preliminary results from an 18-month follow-up survey indicate the infection rate among IDUs in the Lang Son area has fallen from 47 percent to 37 percent, Hammett says.
Although the numbers so far are relatively
small - about 1,500 users are involved on
a regular basis - it is no small achievement
to reach a population that wants desperately
to remain invisible in societies that
view their addiction as a "social evil" and
commit them to punitive re-education
camps.
Drug users in both countries are often
"highly stigmatized, severely oppressed
and mistreated," notes Hammett, so that
gaining their trust and cooperation, along
with that of the surrounding communities,
has been a major challenge. A crucial
element of the project has involved
training 60 current and former drug users
as "peer educators" who are paid to hand
out sterile needles, collect used ones for
disposal, and distribute vouchers that
cooperating pharmacists will exchange for
clean needles and syringes, condoms, and
sterile water for injection.
Several of the peer educators
have given moving testimonials
that by participating in the
project they were motivated to
reduce their drug use.
Local law enforcement has agreed not to
harass participants, but the IDUs are
fearful, particularly in Vietnam, and some
have even been arrested. In an interview
with The Wall Street Journal, Hammett
explained that the peer educators are a
tough workforce to manage, but ideal for
the job. "Drug users have a built-in
credibility" with other drug users, he told
the reporter.
Moreover, they perceive potential problems
that researchers and health officials might
miss. One group of peer educators in
Vietnam lobbied to relocate a project
center away from a police station,
complaining that IDUs would feel they
were being led into "the mouth of the tiger,"
Hammett reports.
Square on China-Vietnam border indicates project location
Another major obstacle has been the
widespread fear that distributing needles and syringes
encourages drug use. The Guangxi/
Lang Son project includes a public
education component that surveys
community attitudes and attempts to
both improve understanding of HIV
prevention and reduce stigmatization of
drug users and people living with HIV
and AIDS. Public awareness efforts
may eventually include, for example,
billboards depicting the number of dirty
needles collected that might otherwise
have infected barefoot children.
Researchers have collected data
demonstrating that there is no relationship
between clean needle distribution
and increased drug use.
This information is disseminated in the
communities, along with messages to
counter common misconceptions such as
the belief that AIDS can be "caught" by
eating with or hugging an HIV-positive
person. In follow-up surveys, community
attitudes toward the project and knowledge
of HIV have improved in both countries.
Numerous studies of
needle exchange
programs - there are
active programs in at
least 40 countries,
including the United
States - have
confirmed that
distributing clean
needles does not lead
to increased drug use
but does lead to a
decrease in the overall
prevalence of HIV
infections. That
conclusion has been
echoed by the U.S. Centers for Disease
Control and Prevention and former U.S.
Surgeon General David Satcher, among
others.
Asia is a global indicator for the
next phase of the AIDS epidemic.
There is a window of opportunity
to affect its course and reduce its
severity.
There is even anecdotal evidence,
Hammett has noted, that the peer intervention
program could lead to some decline in
the use of drugs. "Several of the peer
educators have given moving testimonials,"
he said, "that by participating in the project
they were motivated to reduce their drug
use." In fact, about half of the peer
educators quit using drugs after
participating in the program in Guangxi,
according to Dr. Liu Wei, director of the
Center for HIV/AIDS Prevention and
Control there. The Guangxi Centers for
Disease Control currently plans to expand
the program to cover some other parts of
the province.
Despite the supportive evidence, most
national governments, including the United
States, will not fund needle exchange
programs. The Abt Associates project has
been funded in part by the National
Institute on Drug Abuse, which supports
the research, and a grant from the Ford
Foundation covers other costs, including
needles and syringes.
Project Director Ted Hammett (center) with Dr. Nguyen Minh Phuong (far right) from the Lang Son Provincial Health Service and other Vietnamese colleagues. The sign reads: "Let's protect all children in the world from HIV/AIDS."
Funding for the Guangxi/Lang Son
project is secure for one more year.
Hammett is meanwhile searching for
commitments to continue the program
and to expand its focus to target
women at high risk for HIV: female
IDUs, sex workers, and sexual
partners of male IDUs. As Hammett
explains, these groups of women are
the critical links between male IDUs
and the general population. "HIV
prevalence among sex workers is
increasing fairly rapidly in some parts
of China and Vietnam," Hammett
said. "Prevalence among pregnant
women is still quite low, but beginning
to creep up. There is some data from
Vietnam that suggests that the
problem of crossover of HIV to the
general population is reaching serious
dimensions."
In fact, according to the World Health
Organization, Vietnam is still in a "concentrated
epidemic stage but there is a clear spread
to the general population," with more than
one percent of pregnant women testing
HIV positive in four provinces.
Dr. Peter Piot, executive director of
UNAIDS, told delegates at the Bangkok
conference in July that Asia, with 60
percent of the world's population, is a
global indicator for the next phase of the
AIDS epidemic. There is a window of
opportunity, he said, to affect its course
and reduce its severity. If the opportunity is
wasted, many experts agree, the Asian
epidemic could be a disaster that would
dwarf the AIDS crisis in Africa.
The intervention in Guangxi-Lang Son is a
small roadblock in the path of the epidemic,
but it represents an international willingness to
attempt strategies that would have been
politically infeasible in the recent past. As a
result, there's a chance, Hammett says, that
the disease will stumble at the border.
In addition to the cross-border prevention
project in China and Vietnam, Abt
Associates staff at the XV International
AIDS Conference in Bangkok, Thailand
presented more than a dozen examples
of their HIV/AIDS projects for colleagues
and delegates from around the world.
Their work addressed a cross section of
HIV/AIDS issues relevant to stakeholders
throughout the AIDS community, including
donors, patients, policymakers, and
researchers.
A recurring theme in the presentations was the urgent need to prepare the ground for the launch and
expansion of large-scale antiretroviral therapy (ART) programs funded by the United States and the
Global Fund to Fight AIDS, Tuberculosis, and Malaria. As huge sums for HIV/AIDS programs begin to
flow into developing countries, there is a growing necessity, the investigators agreed, to ensure equitable
access to services, track funds, train personnel, monitor results, and plan for long-term financing.
Out-of-Pocket Expenditures are a Burden for Households: Abt Associates experts have adapted
National Health Accounts methodologies to estimate HIV/AIDS expenditures and used these subanalyses
to track the expenditures in Rwanda, Kenya, and Zambia. The analyses presented at the
conference made clear that out-of-pocket medical expenses among AIDS-affected households in the
poorest nations represent an insupportable burden, more than half of all national expenditures for AIDS.
Families caring for one or more AIDS patients typically become indebted and unable to support their
basic needs. In Nigeria, for example, where per capita income is $300, AIDS patients are asked to pay
about $318 yearly for tests, drugs, and care.
The Cost of ART is More than the Cost of Drugs:
Abt Associates cautioned that donors and
beneficiary countries alike are underestimating the true cost of ART by focusing on the price of drugs.
The costs associated with testing, treatment monitoring, counseling, and treatment of opportunistic
infections could equal or exceed the cost of antiretroviral (ARV) medications. Moreover, in some
countries, a lack of trained healthcare workers may constrain ART programs sooner than a lack of
funding.
Low Cost Drugs Will Make a Difference for PEPFAR: The cost of ARV drugs is, however,
exceedingly relevant to meeting the goal set by the President's Emergency Plan for AIDS Relief
(PEPFAR) of treating 2 million people by 2008. According to Abt Associates, only if low-priced drugs -
probably generic versions of ARV patented medications priced at about $300 per patient per year - are
used, will the PEPFAR budget be adequate to meet that goal.
Treatment Rationing Demands Careful Monitoring: When treatment programs are unable to meet
demand, the issue of rationing will surface, as it has in Mexico, Senegal and Uganda. Abt Associates
presented case studies from those countries and called for monitoring programs to determine whether
patients who meet treatment criteria are, in fact, receiving therapy and services.
Transition Programs are Needed for U.S. Inmates: Access to medical and social services for
HIV-positive inmates in the United States must improve. In the Corrections Demonstration Project, which
expands HIV services for inmates and releasees, and for which Abt Associates is a subcontractor,
infection rates for HIV and other sexually transmitted infections are five times higher among inmates than
the general population. Transition programs can help ensure that treatment continues after infected
inmates rejoin the general population.
Proven Strategies Can Strengthen Health Systems: While researchers and implementers hasten to
assemble data on the best ways to tackle HIV/AIDS as a relatively new health crisis, lessons from the
past are useful. The AIDS community should not overlook successful strategies from programs such as
immunization, family planning, and primary healthcare strengthening. Abt Associates believes strongly
that introducing financing reform, risk-sharing, organizational change, and policy reform, along with
prevention and treatment plans, can help strengthen the framework for dealing with AIDS and other
health challenges.
