A community-based intervention to decrease the prevalence of HIV viremia among people who inject drugs in Vietnam.

Background: In most low-to-middle-income countries, HIV control at the population level among people who inject drugs (PWID) remains a major challenge. We aimed to demonstrate that an innovative intervention can identify HIV-positive PWID in the community who are not treated efficiently, and get them treated efficiently. Methods: Between 2016 and 2020, we implemented an intervention consisting of mass HIV screening of PWID using three annual respondent-driven sampling surveys (RDSS) and a post-intervention evaluation RDSS in community-based organisation (CBO) sites, coupled with peer support to facilitate/improve access to antiretroviral and methadone therapy in Haiphong, Vietnam. The primary outcome was the proportion of identified uncontrolled HIV-positive PWID who achieved viral control. We also estimated the potential effect of the intervention on the proportion of PWID with HIV RNA >1000 copies/mL among all PWID during the study period. Findings: Over the three RDSS, 3150 different PWID were screened, i.e. two-thirds of the estimated population size. They all injected heroin, their median age was of 39 years, 95% were male, 26.5% were HIV-infected, and 78.6% of the latter had HIV RNA ≤1000 copies/mL. Among the 177 PWID identified with an unsuppressed viral load, 73 (41.2%) achieved viral suppression at the final visit. HIV viremia decreased from 7.2% at baseline to 2.9% at the final RDSS (p<0.001). Up to 42% of this observed reduction may be explained by the intervention, in the absence of any external intervention targeting PWID during the study period. Interpretation: Mass community-based screening using RDSS coupled with CBO support is a powerful tool to rapidly identify untreated HIV-positive PWID and (re)link them to care. Funding: NIDA (USA) and ANRS (France).

How has the COVID-19 epidemic affected the risk behaviors of people who inject drugs in a city with high harm reduction service coverage in Vietnam? A qualitative investigation.

INTRODUCTION: The COVID-19 outbreak disproportionally affects vulnerable populations including people who inject drugs (PWID). Social distancing and stay-at-home orders might result in a lack of access to medical and social services, poorer mental health, and financial precariousness, and thus, increases in HIV and HCV risk behaviors. This article explores how the HIV/HCV risk behaviors of PWID in Haiphong, a city with high harm reduction service coverage in Vietnam, changed during the early phase of the COVID-19 pandemic, and what shaped such changes, using the risk environment framework. METHOD: We conducted three focus group discussions with peer outreach workers in May 2020 at the very end of the first lockdown, and 30 in-depth interviews with PWID between September and October 2020, after the second wave of infection in Vietnam. Discussions and interviews centered on the impact of the COVID-19 pandemic on their lives, and how their drug use and sexual behaviors changed as a result of the pandemic. RESULTS: The national shutdown of nonessential businesses due to the COVID-19 epidemic caused substantial economic challenges to participants, who mostly were in a precarious financial situation before the start of the epidemic. Unsafe injection is no longer an issue among our sample of PWID in Haiphong thanks to a combination of different factors, including high awareness of injection-related HIV/HCV risk and the availability of methadone treatment. However, group methamphetamine use as a means to cope with the boredom and stress related to COVID-19 was common during the lockdown. Sharing of smoking equipment was a standard practice. Female sex workers, especially those who were active heroin users, suffered most from COVID-related financial pressure and may have engaged in unsafe sex. CONCLUSION: While unsafe drug injection might no longer be an issue, group methamphetamine use and unsafe sex were the two most worrisome HIV/HCV risk behaviors of PWID in Haiphong during the social distancing and lockdown periods. These elevated risks could continue beyond the enforced lockdown periods, given PWID in general, and PWID who are also sex workers in particular, have been disproportionately affected during the global crisis.

Drug users in Hanoi, Vietnam: factors associated with membership in community-based drug user groups.

BACKGROUND: A syndemic conjoins injection drug use, incarceration, and HIV in Vietnam, where there is a need for programs that empower people who use drugs to minimize the harms thereby produced. Here we present a post-hoc evaluation of the organizing efforts of the Centre for Supporting Community Development Initiatives (SCDI) with two community-based drug user groups (CBGs) in Hanoi. METHODS: Members (n = 188) of the CBGs were compared to non-member peers (n = 184) on demographic, psychosocial, behavioral and knowledge variables using a face-to-face structured interview that focused on issues of quality of life and harm reduction. Bivariate analyses were conducted, and variables significantly associated with membership at p < 0.10 were included in a multivariate model. RESULTS: Variables associated with membership in the CBGs in the multivariate model included increased self-efficacy to get drug-related health care (OR 1.59, 1.24-2.04), increased quality of life in the psychological (OR 2.04, 1.07-3.93) and environmental (OR 2.54, 1.31-4.93) domains, and greater history of interactions with police about drugs (OR 3.15, 1.79-5.52). There was little difference between members and non-members on injection-related harms except in the domain of knowledge about opioid overdose. Among the 114 current injectors (30.6% of the sample), low rates of unsafe injection practices were reported, and low statistical power limited the ability to conclusively assess association with membership. CONCLUSIONS: Although the CBG members displayed higher levels of well-being and access to healthcare than non-members, further longitudinal study is required to determine if these are a result of membership. The CBGs should pay more attention towards meeting challenges in responding to specific health issues of those who continue to use drugs including HIV, hepatitis, and drug overdose.

Effect of health expenses on household capabilities and resource allocation in a rural commune in Vietnam.

BACKGROUND: Significant health expenses can force households to reduce consumption of items required for daily living and long-term well-being, depriving them of the capability to lead economically stable and healthy lives. Previous studies of out-of-pocket (OOP) and other health expenses have typically characterized them as "catastrophic" in terms of a threshold level or percentage of household income. We aim to re-conceptualize the impact of health expenses on household "flourishing" in terms of "basic capabilities." METHODS AND FINDINGS: We conducted a 2008 survey covering 697 households, on consumption patterns and health treatments for the previous 12 months. We compare consumption patterns between households with and without inpatient treatment, and between households with different levels of outpatient treatment, for the entire study sample as well as among different income quartiles. We find that compared to households without inpatient treatment and with lower levels of outpatient treatment, households with inpatient treatment and higher levels of outpatient treatment reduced investments in basic capabilities, as evidenced by decreased consumption of food, education and production means. The lowest income quartile showed the most significant decrease. No quartile with inpatient or high-level outpatient treatment was immune to reductions. CONCLUSIONS: The effects of health expenses on consumption patterns might well create or exacerbate poverty and poor health, particularly for low income households. We define health expenditures as catastrophic by their reductions of basic capabilities. Health policy should reform the OOP system that causes this economic and social burden.

Impact of health insurance on health care treatment and cost in Vietnam: a health capability approach to financial protection.

We applied an alternative conceptual framework for analyzing health insurance and financial protection grounded in the health capability paradigm. Through an original survey of 706 households in Dai Dong, Vietnam, we examined the impact of Vietnamese health insurance schemes on inpatient and outpatient health care access, costs, and health outcomes using bivariate and multivariable regression analyses. Insured respondents had lower outpatient and inpatient treatment costs and longer hospital stays but fewer days of missed work or school than the uninsured. Insurance reform reduced household vulnerability to high health care costs through direct reduction of medical costs and indirect reduction of income lost to illness. However, from a normative perspective, out-of-pocket costs are still too high, and accessibility issues persist; a comprehensive insurance package and additional health system reforms are needed.

Coping with health care expenses among poor households: evidence from a rural commune in Vietnam.

With the 1980s "Doi Moi" economic reforms, Vietnam transitioned from state-funded health care to a privatized user fee system. Out-of-pocket payments became a major source of funding for treatments received at both public and private health facilities. We studied coping strategies used by residents of Dai Dong, a rural commune of Hanoi, for paying health care costs, assessing the effects of such costs on economic and health stability. We developed a 2008 survey of 706 households (166 poor, 184 near-poor, 356 non-poor; 100% response rate). Outcome measures were reported episodes of illness; inpatient, outpatient, and self-treatments; out-of-pocket expenditures; and funding sources for health care costs. Households of all income levels borrowed to pay for inpatient treatments; loans are also more heavily used by the poor and near-poor than the non-poor for outpatient treatments. Compared to low cost treatments, the use of loans is intensified for extremely high cost health treatments for all poverty levels, but especially for the poor and near-poor. The likelihood of reducing food consumption to pay for extremely high cost treatment versus low cost treatments increased most for the poor in both inpatient and outpatient contexts. Decreased funding and increased costs in health care rendered Dai Dong's population vulnerable to the consequences of detrimental coping strategies such as debt and food reduction. Future reforms should focus on obviating these funding measures among at-risk populations.