Funding Support

1. Funding Support • National Institute on Drug Abuse, U.S. National Institutes of Health – Research • Ford Foundation (Beijing and Hanoi) – Interventions

2. Overview • Geographic Setting • Cross-Border Dimensions of Drug Use and HIV Transmission • Cross-Border HIV Prevention Project

3. Map of Project Sites China Area of Detail Hanoi Vietnam China Ning Ming City Puzhai Shilang Aidian Tan Thanh Tongmian Key: CaoLoc Town Dong Dang Loc Binh Hop Thanh Large Project Site Langson town Small Border Site Vietnam Geographic Setting

4. Cross-Border Dimensions • Drug Trafficking  Drug Use  HIV Transmission • Drug Trans-shipment Routes Golden Triangle  Vietnam  S. China  Hong Kong  The World Source: Beyrer et al., AIDS 2000; 14:75-83

5. Drug Trafficking  Drug Use  HIV Transmission • Heroin availability along trans-shipment routes  shift from traditional opium smoking to heroin smoking/ inhalation  heroin injection (cost efficiency) • Heroin injection  sharing of injection equipment (pharmacy sale of needles/syringes but problems of cost [users often cannot afford needle/syringe once they pay for drug], and limited business hours) • Sharing of injection equipment  HIV transmission

6. Guangxi Province, China: HIV spreads along drug trans-shipment routes

7. Guangxi Province, China: HIV spreads along drug trans-shipment routes Source: Guangxi Center for HIV/AIDS Prevention and Control • 21% HIV prevalence among IDUs in Pingxiang (adjacent to Ning Ming), ~10% in Ning Ming (awaiting Cross-Border project baseline survey – July 2002)

8. Vietnam: Increasing HIV prevalence among IDUs along border with Guangxi • Quang Ninh Province –65% HIV prevalence among IDUs (Sentinel Surveillance, 2000) • Lang Son Province – increasing numbers of cases

9. Vietnam: Increasing HIV prevalence among IDUs along border with Guangxi HIV Prevalence Among IDUs in Lang Son, 1996-2001 Source: Preventive Medicine Center of Lang Son, December, 2001 • Lang Son: ~80% of HIV cases are IDUs, ~21% HIV prevalence among IDUs (Sentinel Surveillance, 2000) – but concern about sampling makes figure uncertain. Awaits Cross-Border project baseline survey – July 2002

10. Cross-Border Dimensions • Small-scale movement associated with heroin purchase/sale • Molecular epidemiology (Beyrer, 2000; Yu, 1998, 1999, 2002; Kato, 1999) suggest cross-border HIV transmission probably from N. Vietnam  S. China: matching strains of Subtype E found on both sides of border • Border between Guangxi and Lang Son – 200 km, mountainous, porous – 1 official crossing,  5 semi-official, many unmonitored

11. Small-scale movement associated with heroin purchase/sale (cont.) • Patterns of movement – influences (from formative research, more to come from project surveys): • Price (lower) and purity (higher) in Vietnam – Chinese users cross into Vietnam to buy/use • Law enforcement activity • Wholesale/retail availability: Chinese dealers buy in Lang Son, sell in Ning Ming; Vietnamese users cross into China to buy/use • Vietnamese IDUs/sex workers live in China (e.g., 30% of IDUs in Aidian are Vietnamese)

12. Cross-Border Dimensions • 3. Trade and Employment • Legitimate business/commercial activity • Migratory labor • “Floating Population” – 1 million in area

13. Cross-Border Dimensions • 4. Ethnic/Family Ties • Common ethnic minority groups on both sides of border (e.g., Zhuang) • Intermarriage common, although illegal and results in loss of nationality.

14. Cross-Border HIV Prevention Project • First-ever cross-border HIV prevention project for IDUs • HIV prevalence at possible “take-off” point in Ning Ming and Lang Son • Cross-border dimensions and opportunities  project concept and design • Project development: 1997-2001 – many challenges

15. Intervention • 6 sites in Lang Son, 4 in Ning Ming • Peer-based education of IDUs • Centers in Ning Ming/Field outreach in Lang Son • Public health/infection control • Collection and safe disposal of used needles/syringes • Social marketing of new needles/syringes • Pharmacy/clinic vouchers (China and Vietnam) • Direct exchange also offered (Vietnam)

16. Intervention (cont.) • Community education • Letters of support from police and other agencies • Regular meetings/community workshops • Job training for peer educators • Support for drug use cessation • Cross-border collaboration

17. Pharmacy/Clinic Voucher – Lang Son Province

18. Pharmacy/Clinic Voucher – Lang Son Province

19. Evaluation • Methods • Pre- and multiple-post intervention followup • Cross-sectional surveys of IDUs (baseline + 6, 12, 24, 36 months) • HIV testing (with counseling) • “Capture-recapture” component  HIV incidence estimation, longitudinal behavior change • KAP surveys in community (HIV knowledge, knowledge of/attitudes toward project) • Process data • Peer educator logs (contacts, collection of used needles/syringes) • Pharmacy/clinic logs (vouchers redeemed)

20. Evaluation (cont.) • Outcomes • Stable HIV prevalence • Low HIV incidence • Reduced high-risk behavior (distributive and receptive sharing of injection equipment) • Reduced high-risk sexual activity • Large-scale safe disposal of used needles/syringes • Increased community awareness of HIV and support for intervention

21. Conclusions • Path-breaking project • Very important opportunity to reduce cross-border HIV transmission and increase cross-border collaboration • Serious challenges in development and implementation • Collaboration in cross-border projects would be useful in many HIV transmission contexts in many parts of the world