PROPOSALS

Document Sample
PROPOSALS Powered By Docstoc
					Situation assessment of drug injecting and its health consequences
               among IDUs in Hanoi City, Vietnam




                  Hanoi School of Public Health
                   Supported technically by WHO




                               2001




                                1
Executive summary

The general objective of the study is to describe the current nature, extent of factors,
risky behaviors influence the spread of injecting and HIIV infection and recommend
appropriate interventions for reducing HIV transmission among injecting drug users
(IDUs) in Hanoi.

Rapid assessment and responses (RAR) methods developed by WHO was used,
including reviewing existing information, geographic mapping of drug use, in-depth
interview, focus group discussion. Representatives of local authorities and mass
organizations from different levels (city, district and communal levels), drug users and
their families have participated in the study.

The number of IDUs has been increased considerably among male, but female drug
users have been also increased, especially among street female sex workers (FSW).
HIV prevalence is rising rapidly to17.5% among IDUs and to 10% among FSWs by
the year 2000. The main drug currently in use is heroin. The rate of sharing needle
over 6 previous months among IDUs is 31.9%. The rate of condom use in recent
sexual intercourse with FSWs is 82.4% but the rate of always use of condom over the
last 12 months is lower (27.9%). The rate of drug users with correct knowledge about
preventive measures of HIV infection is 87.8%. Many interventions on drug and HIV
control have been performed but there is little intervention with direct relation to
reduce HIV risk behaviors of IDUs. Harm reduction prevention is still at small scale.
Although the views of local authorities and community about HIV prevention
measures among IDUs are still different, in general they have tolerant attitude to IDUs
and accept harm reduction approach. Hanoi is at the first stage of HIV epidemics with
high prevalence among high-risk groups as IDUs and FSWs. Appropriate, effective
and prompt actions to prevent the HIV transmission among IDUs are urgently needed.

The intervention model of HIV control in the family and community, integrating with
other health education activities should be strengthened. Peer education and outreach
work with appropriate contents and methods among IDUs should be expanded within
the supportive environment of the community. More services such as voluntary HIV
counseling and testing, STI treatment, care for HIV infected people, and for high risk
and vulnerable people should be established.




                                            2
1. INTRODUCTION
Hanoi city is the capital of Vietnam. It is the cultural, economic and social center of
the country with the population of about 3 millions. It is included of 7 urban districts
(comprising 110 urban communes), and 5 rural districts (comprising 118 rural
communes). In parallel with increasing open-door economic situation, cultural
exchange, business, service, tourist activities, Hanoi also is facing with challenges for
HIV transmission.

According to report of the National Committee of Drug Control, there are about more
than 100.000 drug user in the year of 2000. Annually the money spent for drug by
these people is 2000 billions Vietnam dong (equivalent to 133.3 million USD). Hanoi
and Ho Chi Minh City (HCMC) are main centers for drug trafficking and drug use.
These cities hold up to 51% total number of HIV cases of the country and 56.4%
number of crimes of drug abuse of the country. About 10.000 drug users (including
injecting and non-injecting drug users) in Hanoi were estimated approximately by
Hanoi Sub-Department for Social Evil Control in the year 2000 (among them, about
1,000 drug users were treated in the treatment centers; the relapse rate was very high,
more than 90%). The reports also indicate that number of new drug users still
increased, although with smaller rate than the last few years.

In Hanoi number of HIV infected people found has increased very fast in 1998 and
1999 although total number of people tested is not increased accordingly, even
decreased. The first HIV case was founded in Hanoi in 1993. On the following years
from 1994-1997, there was a slight increase of detected HIV infection. But since
1998, the reported HIV cases have been increased very fast, from 400 to 600 cases
each year, and up to 3,022 cases at 31/12/2001. HIV infections were detected at all 12
districts. Among HIV reported cases in Hanoi, drug use account for 79.6%. 93.7% of
HIV infection cases were male. HIV infected cases were predominantly among the
age group between 20 and 29 years old (65%). There were 264 reported AIDS cases;
among them 152 died (57.6%). Result from sentinel surveillance showed that HIV
infection prevalence increased among high-risk behavior groups, especially among
IDUs and female sex workers (FSWs), and sexually transmitted diseases (STD)
patients since 1998. In 2000, HIV prevalence was 17.5% among IDUs, 10% among
FSWs, and 3% among STD patients.

Drug use and HIV infection issues were highly concerned
by   Vietnamese   government,   mass  organizations  and
community. But a comprehensive research of the present
drug use situation and its health consequences has been
not yet carried. Although     several interventions have
been carried out, but not systematically, lacked of
integration, and especially not concentrated on reducing
health consequences of drug use.
                                           3
In order to address this problem, Faculty of Public Health, Hanoi Medical University
has cooperated with Hanoi AIDS Bureau to implement a research project on
“Situation assessment of drug injecting and its health consequences among IDUs in
Hanoi City, Vietnam“. This study is supported technically by WHO. It is a part of
WHO second stage research project, which is being implemented simultaneously at 12
cities in the world. The WHO methods for rapid assessment and responses (RAR) was
used. The data were collected in the period from March to June, 2001.

2. STUDY DESIGN
2.1 Objectives.

The study has the following objectives:

 Describe the current nature and extent of drug injecting

 Describe factors influence the spread of injecting and its consequences

 Identify the prevalence of HIV, HBV and HCV infection, overdose and other
  adverse health consequences.

 Describe injecting and sexual behaviors of IDUs leading to adverse health
  consequences.

 Describe the policy responses to drug injecting and adverse health consequences

 Recommend appropriate interventions for reducing reverse health consequences of
  IDU.

2.2 Research team

Research team comprises members from following agencies:

 Faculty of Public Health, Hanoi Medical University, Vietnam

 Hanoi AIDS Committee

 City AIDS Officers

 District AIDS officers

 Health Service, Ministry of Police




                                          4
                  Table 1: List of research team members

                       Name             Position        Organization
Team member #1    Nguyen tran Hien    Vice Dean    Faculty    of    Public
                                                   Health, Hanoi Medical
                                                   University
Team member #2    Tran van Chi,       Lecturer     Faculty    of    Public
                                                   Health, Hanoi Medical
                                                   University
Team member #3    Tran nhu Nguyen     Lecturer     Faculty    of    Public
                                                   Health, Hanoi Medical
                                                   University
Team member #4    Le thi Tai          Lecturer     Faculty    of    Public
                                                   Health, Hanoi Medical
                                                   University
Team member #5    Nguyen minh Son     Lecturer     Faculty    of    Public
                                                   Health, Hanoi Medical
                                                   University
Team member #6    Dao thi minh An,    Lecturer     Faculty    of    Public
                                                   Health, Hanoi Medical
                                                   University
Team member #7    Tran Viet Anh       Lecturer     Faculty    of    Public
                                                   Health, Hanoi Medical
                                                   University
Team member #8    Le vinh Giang       Lecturer     Faculty    of    Public
                                                   Health, Hanoi Medical
                                                   University
Team member #9    Bui hoang Duc       Lecturer     Faculty    of    Public
                                                   Health, Hanoi Medical
                                                   University
Team member#10    Nguyen van Binh     Program      Health Service
                                      Officer      Ministry of Police
Team member #11   Vu cong Thao        Program      Hanoi AIDS Bureau
                                      Officer
Team member #12   Tran quoc Tuan      AIDS         Hanoi AIDS Bureau
                                      Program
                                      Officer
Team member #13   Nguyen       phuong AIDS         Hanoi AIDS Bureau
                  Hoa                 Program
                                      Officer
Team member #14   Vu Dai              AIDS         AIDS Bureau,
                                      Program      Dong da District
                                      Officer



                                     5
                          Name                  Position           Organization
Team member #15      Hoang tan Cuong         AIDS             AIDS Bureau,
                                             Program          Ba dinh District
                                             Officer
Team member #16      Bui van Cuong           AIDS             AIDS Bureau,
                                             Program          Gia lam District
                                             Officer
Team member #17      Pham thi Ngoan          AIDS             AIDS Bureau,
                                             Program          Hai ba Trung District
                                             Officer
Team member #18      Lam tien Ha             AIDS             AIDS Bureau,
                                             Program          Cau giay District
                                             Officer
Team member #19      Nguyen bich Ngoc        AIDS             AIDS Bureau,
                                             Program          Hoan kiem District
                                             Officer
Team member #20      Nguyen van Qui          IDU       pear   Dong da District
                                             educator
Team member #21      Cao duy Toi             IDU      pear Hai ba trung District
                                             educator



     Table 2: List of the members of the Community Advisory
                              Body

             Name                     Position                          Organization
1      Ton that Bach       Rector                              Hanoi Medical University
2      Nguyen anh Tuan     Director                            Hanoi Health Service
3      Pham hoang Nga      Head                                Hanoi AIDS Bureau
4      Do kim Tuyen        Vice Director                       Hanoi Police Service
5      Nguyen      thanh   Secretary                           AIDS Division,MoH
       Long
6      Le ngoc Yen,        Program Officer                     National AIDS Bureau
7      Nguyen vi Hung      Director                            Hanoi Social Evils Department
8      Dao ngoc Phong      Dean                                Faculty of Public Health,
                                                               Hanoi Medical University
9      Nguyen     thanh Director                               Health Department
       Tung                                                    Police Ministry
10     Nguyen van Luan Director                                City Drug Treatment Center


                                           6
11    Nguyen tran Hien Vice-Dean                             Faculty of Public Health,
                                                             Hanoi Medical University
2.3 . Methods

2.3.1 Study geographical areas

 All related existing data for the whole city were collected.

 The in-depth interviews and focus group discussions were conducted in 4 districts
  which were considered as hot areas for drug use and HIV infection: Dong Da, Hai
  ba Trung, and Ba Dinh (urban), and Gia lam (rural). Then in each selected district,
  a commune , which reported high number of drug users, shooting galleries, and
  open for discussions, was selected for the in-depth interviews and focus group
  discussions

2.3.2 Study populations

Representatives of local authorities and mass organizations (such as Youth Union,
Women's Union, Veteran's Union, Fatherland Front, which play an important role in
mobilizing and implementing all activities of the community), drug users and their
families from different levels: city, district and communal.

 Representatives of City AIDS Committee

 Representatives of the City Sub-Department for Social Evil Control.

 Representatives of the City Police service.

 Representatives of mass organizations.

 Representatives of the City Drug Treatment Center.

 Drug users.

 Representative of drug user's family.

2.3.3 Data collection methods

RAR methods developed by WHO were used in this study:

 reviewing existing information

 geographical mapping of drug use. Two data sources were used for mapping the
  distribution of drug use and shooting galleries: reported number of drug users from
  City Sub-Department for Social Evil Control, and from
  group discussions with peer educators for drug users

                                           7
 in-depth interview

 focus group discussion

 direct estimating the number of drug users in 10 hot communes, where higher
  number of drug users reported. (Thanh xuan nam, Hang buom, Phuc tan, Chuong
  duong, Nam Dong, Trung phung, Trung liet, Thanh nhan, Bach mai, Phuc xa). In
  these communes, all drug users were counted and listed by police man who is in
  charge of management of social evils in the commune.

 small survey among IDUs (n=30)

Checklist for data collection were developed based on the study objectives, and
following the suggestions of WHO RAR methods.

2.3.4 Training interviewers

Before conducting the study, the research team was trained as interviewers about RAR
methods for three days. The rapid assessment and response guide on injecting drug use
(IDU-RAR) developed by WHO was used for training.

2.3.5 Study Organization

The City AIDS Bureau was responsible for organizing the in-deep interviews and
focus group discussions.

Public Health Faculty at Hanoi Medical University was responsible for technical
issues such as preparing contents, methods, data collection tools; collecting data,
analyzing data, and writing reports.

2.3.6 RAR process

There was no serious problem on conducting and implementing of the study. Some
representatives were absent because they were busy with other missions but they have
sent someone on behalf to participate interviews and discussions. At the end of the study,
there was a campaign to collect drug users for treatment, the approaching drug users for
testing the questionnaire became more difficult.

RAR data was useful for the research team in adapting the WHO questionnaire in
Vietnam context, both for the contents and the phrasing questions.

2.3.7 Study plan




                                            8
                                    Table 3: Plan for implementation of RAR in Hanoi
                                      February    March        April         May                                              June                   July
                                    29   5    12   19   26   5    12   19   26   2   9    16   23   30   7    14   21   28   4    11   18   25   2    9     16   23
                                    4    11   18   25   4    11   18   25   1    8   15   22   29   6    13   20   27   3    10   17   24   1    8    15    22   29
a/ Pre-RAR
arrangements:
Formation of study
group
initial consultation
and contact with key
informants,
review of existing data,
consulting with City
AIDS Bureau
b/RAR plan:
- establishment of advisory group
- consultation meeting about
methodology, contents and
sources of information
- Planning meeting
- Training
c/ Data collection- Field work
- reviewing existing information
- Geographic mapping of drug
use.
- in-depth interview
- focus group discussion
survey of drug use in 10 hot
communes
d/ Evaluation and report

                                                                            9
-Analyzing data & writing report
- Disseminating RAR findings to
related agencies
-Translate findings to action plan




                                     10
      Table 4: Number of in-depth interviews and focus group discussions

                                                               In-depth     Focus
                                                              interview     Group
                                                                          discussion
At the city level:
- Representatives of City AIDS Committee                         1          1x8*
- Representative of City Sub-Department for Social Evil          1
Control                                                          1
- Representative of City Police Department                       1           1x8
- Representative of City Drug Treatment Center                               1x8
- Staff members of health care service of the city police.

At the district level:
- Representatives of District Committee of AIDS, Drug and        4
- Prostitution Prevention.                                       4
- Representatives of District Sub-                                           2x8
Department for Social Evil Control                               4
- Representatives of District Police Department                  4
- Representatives of District Health Service
- District AIDS program officers                                             2x8
- Program officers of District Children Care and Protection
Program                                                                      1x8
- Peer education and "Friend help friend" groups                             2x8

At the community level:

- Members of District Committee of AIDS, Drug and                20          2x8
Prostitution Prevention, including representatives from
community mass organizations**
- Drug users***                                                  4           4x8
- Families of drug users                                         4           2x8
- Peer education group and "Friend help friend" group                        2x8
Sex workers from Rehabilitation Center                                       2x8
Street children                                                              1x8
Total                                                            48         23 x8
*
  The people interviewed participated also in focus group discussions
**
  All different administrative bodies selected at different levels were government
agencies. In general, non-governmental organizations were limited in Vietnam.
***
    Drug users in the community were approached by peer educators to invite for the
study.




                                           11
3. RESULTS

3.1.   Contextual assessment


      Vietnam is a nation in South-East Asia. borders to China at the North, to Laos
       and Cambodia at the West, and to the East Sea and Pacific Ocean at the East
       and South West.
      Vietnam is an agricultural nation in which the agriculture products share a high
       percentage in national economy. The Vietnam economy as a whole is being in
       transition to a market economy with increasing socio-economic differentiation
       between rich and poor and between urban and rural areas.
      Hanoi is the capital of Vietnam, the center of political, socio-economic and
       culture of the country with an area of 921 square kilometers and a population of
       2,866,000 people, with 12 districts (7 urban and 5 rural districts).
      Along with the open policy, economic development and rapid urbanization,
       many negative social consequences were occurring. Hanoi is facing great
       challenges on demographic mobility, free emigration of manual workers from
       other provinces, unemployment, drug use and prostitution.




3.1.1 Geographical, political and socio-economic situation

Vietnam is a nation in South-East Asia. It locates at the eastern coast of the
Indochinese peninsula, with an area of 330,991 square kilometers and a population of
76,324,750 people. Vietnam borders to China at the North, to Laos and Cambodia at
the West, and to the East Sea and Pacific Ocean at the East and South West. As the
Vietnam territory is situated entirely in the tropic rather than equatorial zone, the main
climatic feature of Vietnam is conditioned by tropical monsoon with the average
temperature of 22C- 27C, annual rainfall of 1,500 - 2,000 mm and relative humidity
of 80%.

Hanoi is the capital of Vietnam with an area of 921 square kilometers and a
population of 2,866,000 people. There are four seasons with an average temperature
of 23,2C and an annual rainfall of 1,800 mm. Hanoi is not only a center of socio-
economic and culture, but also a joining point of communication between northern
and southern provinces. Hanoi, in the other hand, is facing great challenges on
demographic mobility, free emigration of manual workers from other provinces,
together with unemployment and social evils. Poor quarters, slum areas, and so-called
"xom lieu" (venture hamlet), which have not been properly administered, still exists
and become the residence of many jobless and criminal individuals, and being the "hot
spots" for drug trafficking, drug use, prostitution and other social evils.



                                             12
3.1.2 Politic features
The main features of the politic system is described as following:

      People's Council is a state powerful organization, which voted by the people,
       and responsible for the execution of constitution and laws.

      People Committee, voted by People's Council is an executive body of the
       People's Council, responsible for execution of constitution and laws, proposed
       by People's Council and higher levels.

      The Government is an executive body of the National Assembly, is the highest
       level of administration of the Republic Socialist of Vietnam. The main function
       of the Government is to fulfil all political, socio-economic, cultural and
       security tasks assigned by the National Assembly, according to Article 109,
       Constitution of the Republic Socialist of Vietnam..

3.1.3 Socio-economic features

Vietnam is an agricultural nation in which the agriculture products share a high
percentage in national economy. Annual agricultural product is of 98,852.3 billions of
VND, as compared with 150,684.6 billions of industrial product. About 4% of
working-age population have no economic activities. The Vietnam economy as a
whole is being in transition to a market economy with increasing socio-economic
differentiation between rich and poor and between urban and rural area

Hanoi has 12 districts (with 7 urban and the 5 rural districts). Although 7 urban
districts represent only one-third of surface, they account for three-quarter of
population. Hanoi is a center of politics, economy, and culture of the whole country.
While agricultural product is only 1,271 billions of VND, the industrial product is as
many as 12,047.9 billions. According to the Annual Statistics of the Ministry of
Health, the rate of unemployment in Hanoi is actually 9.9%. There is close
relationship between drug addiction and unemployment. According to the 1999 annual
report of the Hanoi Sub-Department for Social Evils Control, the city has about
10,000 drug users. Among them, 63.2% are jobless, only 14.9 % of drug users have
regular job. (Source: City Sub-Department for Social Evil Control, Review Meeting
for drug use survey in Hanoi, 1998)

Along with the open policy, economic development and rapid urbanization, many
negative social consequences were occurring:

      Restaurant, dancing clubs and other entertainment facilities were growing,
       followed by such social problems as prostitution and drug addiction. According
       to the City Service of Culture and Information and Service of Police, by May,
       2001, there were about 1,000 "karaoke" shops, more than 20 dancing clubs
       with 3500 bargirls; 75% of them come from other provinces (New Hanoi
       Newspaper, June 20, 2001).
                                              13
     The number of seasonal workers from other provinces were increasing who
      have low living-condition and lack of management, which facilitate social
      problems such as prostitution and drug addiction.

3.1.4 Religion and belief

Buddhism is the main religion of Vietnam accounts for 80% of population.
Catholicism represents 10% of population, mainly concentrated at Ninh Binh and Bien
Hoa provinces. Hoahao Buddhism is only of 1.4% of population and mainly at the
South-West of Mekong delta area. It seems that it has is no relationship between
religion and drug addiction.




                                        14
   Table 5: Some main geographical, socio-economic and health indicators
                                                       Vietnam           Hanoi
* 1999 Population (thousand)                                78 705          2 866
                      2
* Population per km                                            227          927,4
* Annual population growth (%)                                   1.8        13,24
* % Population urbanized                                         21
* Crude death rate (1999) (per thousand)                          7           3,99
* Crude birth rate (1999) (per thousand)                         21         17,23
* Life expectancy at birth (1999)                                68
* Total fertility rate (1999)                                    2,5             1.9
* Under five mortality rate (1999)                               40         11.85
* Infant mortality rate (1999)                                   31              8.0
* Low birth weight (1999)                                        17              7,0
* Rate of malnutrition among children under 5(%)                 39           23,6
* GNP per capita (US$) (1996)                                  370
* Total adult literacy rate (1994)                               91
* % Population with access to safe water                         56           87.9
* % Population with access to adequate sanitation                73           59.3
* Health budget per capita (US$)                                 4.3
* Estimated number of drug users (IDUs) (2000)             129,000         10.000
* Estimated number of HIV positive IDUs (2000)       21,000-31,000     1.100-1.800
* Estimated AIDS cases among IDUs                      1.000-1.500
Data sources
 UNICEF, Global Children Status 2001
 Hanoi Health Service. Summary of health statistics, 1996-1998
 Ministry of Health. Estimation and projection of HIV/AIDS in Vietnam, 2,000-2,005




                                           15
3.2 Drug use

3.2.1 Current situation of drug use in Vietnam


                      Current situation of drug use in Vietnam

     For a long time, opium production has been known in Vietnam. Since 1988
      the country has been progressively opening its borders and changing its
      economic market structure. Vietnam is facing the serious problems of
      production, trafficking and abuse of illicit drugs.
     Drug use is expanding and now is reported in almost provinces of the
      country. The total number of drug users in whole Viet Nam officially was
      estimated to reach about 129,705 in 1999.
     There was no clear borderline between social groups of IDUs. They belong
      to a group just because they injected in the same shooting gallery or sharing
      the drugs. Injectable drug were ready available in shooting galleries. They
      shared drug solution out of a common container. Needles and syringes were
      ringed in the common and same water container.
     In urban centers of Vietnam opium was injected in a large extent, and often
      mixed with other psychotropic drugs. Opium injecting was used commonly
      because it was cheaper and has better physical effects over the other route of
      use. Many IDUs combined opium with barbiturates such as dolargan or
      valium. Recently, heroin is more common among drug users.
     Throughout the country, injecting drug use was varied, from province to
      province, from 10% to 100%. By regions, the injecting proportion was 20%
      in the northern mountainous area and in the Red River delta, 10 % in the
      northern central area, 65% in the southern central and plateau area and 60 %
      in the Mekong delta area.



Like many countries in South East Asia, Vietnam is facing the serious problems of
production, trafficking and abuse of illicit drugs. For a long time, opium production has
been known in Vietnam. It became more widespread in the latter half of 19th century.
After independence in 1945, the Government made great efforts to eliminate poppy
cultivation which by early 1960’s had proved largely successful. But in 1970’s and
1980s, the cultivation of poppy opium in the northern mountainous provinces still
remained. During the war years drug use intensified in the South, with increasing
populations injecting. Since 1988 the country has been progressively opening its borders
and changing its economic market structure. The gap between rich and poor increased.
Drug use is expanding and now is reported in almost provinces of the country. Recently
while local opium production has decreased, illicit drug trafficking is increasing.
Increased seizures of opium in border areas and of heroin suggests that Vietnam is being
targeted by international drug traffickers as a transit country. Recent seizures shows a
clear trend of increasing trafficking of heroin from neighboring countries into Vietnam
for domestic use and through Vietnam to North America and Australia. The total number
                                           16
of drug users in whole Viet Nam officially is estimated to reach about 129,705 in 1999.
(Ministry of Labor-Invalid and Social Affairs (MOLISA). Reports of drug use and
prostitution situation 1999. Hanoi 2000).

Drug use subcultures display distinct characteristics in various regions. In the Nod,
traditional opium smoking was widespread practice in the mountainous provinces where
poppy opium was cultivated and opium addition was spreading to other provinces. In the
South, heroin abuse was a serious problem during the second Indochina war and
intensifies during the American war years. Injecting drug use is a much older habit, more
diverse and more open than in the North. Places for injecting are dealers' locales but also
public places like city parks. Many IDUs are injecting already for long periods of times
and most of them are middle-aged men. In many places a majority of IDUs receive
injections from dealers, who are the only persons possessing the needed injection
equipment. IDUs found in all social classes, but mainly in particular social groups who
are poor, unemployed and vulnerable. It seems that there is little travel of IDUs to other
cities. There was no clear borderline between social group of IDUs. They belong to a
group just because they injected in the same shooting gallery or sharing the drugs.

While opium traditionally has been smoked in other Asian countries, in urban centers of
Vietnam opium is injected in a large extent, and often mixed with other psychotropic
drugs. In addition, Vietnam is close to the Golden Triangle of northern Thailand,
Myanmar and China where much of the world’s opium is produced. Therefore
recently that factor together with other factors such as rapid urbanization and socio-
economic changes put the country at risk of further increasing drug problems,
including the re-emergence of heroin abuse. Opium injecting is used commonly
because it is cheaper and has better physical effects over the other route of use. Many
IDUs combined opium with barbiturates such as dolargan or valium. Throughout the
country, injecting drug use is varied, from province to province, from 10% to 100%. By
regions, the injecting proportion is 20% in the northern mountainous area and in the Red
River delta, 10 % in the northern central area, 65% in the southern central and plateau
area and 60 % in the Mekong delta area.( Ministry of Labor-Invalid and Social Affairs
(MOLISA). Reports of drug use and prostitution situation 1999. Hanoi 2000)

Injectable drug are ready available in shooting galleries. In many places a majority of
IDUs receive injections from dealers, who are the persons possessing the needed
injection equipment. In the pass, the proportion of IDUs who shared needle was very
high, and sharing needles was considered ”normal”, particularly when injecting with
close friends or a person who look healthy. There is no special belief concerning to the
needle sharing. The main reason is that they do not have time and condition to sterilize
or use disposable needle and syringes due to "police campaign". Most of IDUs injected
at shooting galleries said that the drug solution may become infected during the
preparation process. They shared drug solution out of a common container. Needles and
syringes were ringed in the common and same water container. Most IDUs have
negative views about injecting. They are willing to stop injecting drugs. But they do not
have supportive environment to change behavior.

                                            17
3.2.2 Current situation of drug use in Hanoi City




                     Current situation of drug use in Hanoi City

     Opium addiction appeared long time ago in Hanoi. It nearly controlled
       during the anti-American war, but reappeared at the early 1990s, then has
       been increasing since 1996.
      In previous years, opium has been mainly used but now heroin use becomes
       more common.
      Currently about 10,000 drug users were estimated in Hanoi. Among them,
       20.6% were injecting. However, the proportion of injecting among drug users
       is increasing because of an advantageous cost-effectiveness of injecting.
       The shift from injection to smoking is difficult and very few people can
       practice.
      Recently there was a rapid increase of drug use among street sex workers in
       Hanoi. Results of Behavioral Surveillance Survey (BSS) in the year 2000
       show that in Hanoi, the rate of drug use was 43.37% among street FSWs,
       and 17.3% among karaoke-based FSWs.
     Drug use occurs mainly at urban districts at the border areas between
       districts or communes, and at the sub-urban areas, where the management
       was not so strict..
     Majority of drug users were young people, jobless, less educated, and poor.
       They often joined together in group. The interrelationship between drug
       users from different provinces is not common.




Opium addiction appeared long time ago in Hanoi. It rather popularized since the
beginning of nineteenth century but nearly controlled during the anti-American war.
Drug use reappeared at the early 1990s, then was increasing in the years 1996, 1997
(Figure 1). . Hot spots of drug trafficking can be seen in districts such as Hai Ba
Trung, Dong Da, Ba Dinh, Gia Lam, and Cau Giay. (Figure 2). Figure 3 presents 10
communes, which reported highest number of drug users in Hanoi in 1998. Figure 4,
5,6 illustrate the density of drug use and shooting galleries in districts and communes.




                                           18
                             10000                                                                          9284     9468
                                                                                               9040
                              9000
                                                                                      7800
       Reported drug users


                              8000

                              7000

                              6000

                              5000

                              4000                                           3426
                                                                2775
                              3000        2300         2480

                              2000

                              1000

                                   0
                                          1993         1994     1995         1996     1997     1998         1999     2000




                       Figure 1: Trends of reported drug users in Hanoi
    (Source: City Sub-Department for Social Evil Control. Review Meeting for drug prevention
                            program 1998-2000 (Hanoi, May 2001)


                       2500

                                       2098

                       2000                   1917


                                                       1469
                       1500



                       1000
                                                               673
                                                                       500      479   435     406
                             500
                                                                                                      312     279
                                                                                                                     152

                              0
                                       Dong   Hai ba   Hoan   Gia lam Thanh Tay ho    Cau    Thanh Tu liem    Dong   Soc
                                        da             kiem            xuan           giay     tri             anh   son




            Figure 2 : Distribution of reported drug users by district in Hanoi, 1998
    (Source: City Sub-Department for Social Evil Control. Review Meeting for drug use survey
                                         in Hanoi, 1998.)
.
                                                                              19
                         250

                                 209
                                          201
                         200                               185
     No. of drug users


                                                   176

                                                                   151
                                                                            144       142      141      140
                         150                                                                                      138




                         100



                         50



                          0
                               Bach dag Ohuc tan   Dong   Chuong   ruong   Gia lam   Yen phu Nam dong Van mieu   Phuc xa
                                                   xuan    duong    dinh




Figure 3: Drug use situation in 10 communes, which reported highest number of drug
                                 users in Hanoi, 1998
 (Source: City Sub-Department for Social Evil Control, Review Meeting for drug use
                               survey in Hanoi, 1998.)

In 1998, City Sub-Department for Social Evil Control has conducted a survey on drug
use in the whole city. Data was collected by community representatives (People's
Committee, Police, Women's Union, Office for Social Evil Control) from all 228
communes of the city, using standard data collecting forms. The data was collected for
the whole city, in each community, on the street, at public areas, in the treatment
centers ect. (City Sub-Department for Social Evil Control, Review Meeting for drug
use survey in Hanoi, 1998). This data is annually updated by the system of social evil
control from the community to the city level.

In the year of 2000, in Hanoi, 10,300 drug traffic cases have been depicted with
19,500 arrests, seizing 60 kg of heroin, 576 kg of opium, 6,844 packs of pills, 2,200
kg of marijuana, 119,465 drug ampoules, 17,000 pills of synthetic ecstasy, and 516 g
of amphetamine.

According to reports of the Sub-Department of Social Evil Control in the period 1999-
2000, and the results from focus group discussion, it seems that number of drug use
was increasing not as much as previous years. However, BSS results show a high
prevalence of drug use among female sex workers. The proportion of injecting among
drug users was increased. Currently about 10,000 drug users were estimated in Hanoi.




                                                                      20
"Drug use in Hanoi began to increase since 1995, and have increased continuously in
comparison with previous years. Such new drug users come from other provinces
among free laborers, and students who are living far from the family, and out of
control of the family" (an injecting drug user, male, 33 years old)

Drug use occurs mainly in urban districts. In-depth interviews show that drug
injection was commonly seen where there is a complicated network of narrow alleys
and lanes, which facilitating the escape. Such areas were at the border areas between
districts or communes, and at the sub-urban areas, where the management was not so
strict. Public toilets and such dirty areas were also injecting places of drug users. A
report of the Sub-Department for Social Evil Control shows that in December 1988,
the were 10,001 drug users representing 3.5% of total population. Among them,
20.6% were injecting. However, drug injection was also increasing. Drug users from
urban districts represent 67.7%. Majority of drug users were young people, jobless,
less educated, and poor. . Three quarters have lees than 9 years in the schools. They
often joined together in group. The interrelationship between drug users from different
provinces is not common. Results from focus group discussion show that that drug use
was prevalent in areas where the level of education and employment was low, such as
in slum or "xom lieu" "venture" areas. The people living in these areas may not aware
about harmful effects of drug and the importance of drug control program.

"Every drug users has to join together in group, such as schoolboys with schoolboys.
Workers cannot join to schoolboys. Employed drug users join in a group,... jobless
individuals in another group. Schoolboys and students are joining together in a
group..... Thieves and ruffians are in another group" (an injecting drug user, male, 32
years old)

"There is little relation between drug users in Hanoi and individuals from other
provinces" (an injecting drug user, male, 39 years old)

For the reasons for switching from smoking to injecting, the majority of IDUs point
out that economy challenge is the main cause.

"It depends upon the pocket.. If the cost for drug is as many as 200,000 VND while
you can gain only 50,000 VND, you have to choose injection." (an injecting drug user,
male, 26 years old)

In addition, there are some other reasons such as "...smoking is more healthy but it is
not enough to satisfy the need for drug, so, injection is preferable....Injection brings
rapidly to effect, while smoking requires a wind-tight space" (an injecting drug user,
male, 32 years old)

Currently, many types of drugs are available in the market, but drug users commonly
used heroin. In previous years, opium has been in use but now becomes less.

"Black opium has impurity, it causes fever when injected, ...white heroin is not so..."
(an injecting drug user, male, 40 years old)
                                          21
Recently there was an rapid increase of injecting drug use among sex workers in
Hanoi City. Results of Behavioral Surveillance Survey (BSS) in the year 2000 show
that in Hanoi, the rate of drug use was 43.3% among street FSWs, and 17.3% among
karaoke-based FSWs. The majority of street FSWs have ever served at karaoke bars,
restaurants or night-clubs and have been discharged after being addicted, and
becoming street FSWs. At the same time, they have shifted from drug smoking to
injecting because of an advantageous cost-effectiveness of injecting. However, some
of them were involved in drug use by their patron in order to make them being easily
controlled.

"The female did not start with drug use nor selling sex for drugs...They often involve
in sex work first, then drug use". (an injecting drug user, female, 32 years old)




                                         22
                                                                    1 DOT = 100 DRUG USERS




                      Figure 4: Spot map of drug users by districts in Hanoi, 1998
(Source: City Sub-Department for Social Evil Control. Review Meeting for drug use survey in Hanoi, 1998)

                                                  23
                                                   .

                                                             1 DOT = 20 DRUG USERS




                           Dong Anh



                             Ba dinh
                                                        Hoan kiem


      Cau giay
                                Dong da

                                                       Hai ba trung
                       Thanh xuan


                                    Thanh tri

                    Figure 5: Spot map of drug users by communes in Hanoi, 1998
(Source: City Sub-Department for Social Evil Control. Review Meeting for drug use survey in Hanoi, 1998)


                                                  24
                         Dong Anh


                      Ba dinh
                                                 Hoan kiem
Cau giay

                    Dong da

                                                       Hai ba trung
      Thanh xuan




            Figure 6. Spot map for drug shooting areas in Hanoi
           (Source: Group discussion among injecting drug users)
                                    25
             Table 6: General characteristics of drug users in Hanoi

     Characteristi           Categories                    n                %
            cs
1    Age group     - < 15                                   24             0,2
     (yrs.)        - 15 - 18                               596             5,9
                   - 18 - 25                              4088            40,9
                   - 25 - 30                              2282            22,8
                   - 30 - 40                              2301            23,0
                   - > 40                                  710             7,1
2    Gender        - Male                                 9580            95,8
                   - Female                                421             4,2

3    Ethnicity       - Kinh                              9.933            99,3
                     - Others                               68             0,7
4    Religion        - Buddhism                          7.121            71,2
                     - Catholics                           248             2,5
                     - Others                             2632            26,3
5    Education       - Illiterate                          152             1,5
                     - Primary (1-5)                      1459            14,5
                     - Secondary I (6-9)                  5661            56,6
                     - Secondary II (10-12)               2347            23,5
                     - Vocational Training                  93             0,9
                     - University                          288             2,9
6    Occupation      - Unemployed                         6250            62,5
                     - Farmer                              631             6,3
                     - Worker                              536             5,4
                     - Government staff                     83             0,8
                     - Pupils                              154             1,5
                     - Student                             356             3,6
                     - Trader                              314             3,1
                     - Others                             1677            16,8
7    Job status      - No job                             6324            63,2
                     - Permanent job                      1489            14,9
                     - Part time job                      2188            21,9
8    Family          - High                               1099            11.0
     economic        - Medium                             5292            52,9
     status          - Low                                3610            36,1

9    Criminal        - Yes                                 6632            66.3
     records         - No                                  3372            33,7
(Source: City Sub-Department for Social Evil Control, Review Meeting for drug use
survey in Hanoi, 1998)


                                        26
                       Table 7: Drug use practices of drug users

                                                                     Frequency
         Characteristics                                         n               %

 1       Way of         - Smoking                               2246             22,5
         drug use       - Sniffing                              5649             56,5
                        - Injecting                             1554             15,5
                        - Combination                            511              5,1
 2       Drug use       - less than 1 year                      2339             23,4
         duration       - from 1-3 years                        5294             52,9
                        - more than 3 years                     2368             13,7
 3       Drug types     - Opium                                 1698             17.0
                        - Re-extract opium                       577              5,8
                        - Morphine                                61              0,6
                        - Dolargan                                11              0,1
                        - Marijuana                               08              0,1
                        - Heroin                                7555             75,6
                        - Amphetamine                             02             0,02
                        - Others                                  89              0,9
 4       Places for     - At home                               1752             17,5
         drug use       - Shooting gallery                       392              3,9
                        - Changeable place                      7857             78,6
 5       Reason for     - Curiosity                             2791             27,9
         drug addict    - Looking for strange feeling           2309             23,1
                        - Being induced                         3181             31,8
                        -Treatment                               199              2.0
                        - Disappointment                         448              4,5
                        - Following other family member          267              2,7
                        who uses drug                            806              8,1
                        - Others
 6       Number of      - 1-2 times                             6032             60,3
         treatment      - 3-5 times                             1275             12,6
                        - More than 6 times                      145              1,4
 7       Need           - being treated from drug addiction     5298             53.0
                        - Having a job                          2079             20,8
                        - Come back home                         473              4,7
                        - No need                               2187             21,9
 8       Treatment      - City drug treatment center             481              4,8
         place          - Center for social diseases              34              0,3
                        - Tan trieu Center                        80              0,8
                        - District                               258              2,6
                        - Community                              510              5,1
                        - At home with control of others        1568             15,7
                        - At home with self control             4487             44,9
                        - No treatment                          2583             25,8

(Source: City Sub-Department for Social Evil Control, Review Meeting for drug use survey in
Hanoi, 1998)
                                            27
Heroin is a main drug in use by drug users.

"We prefer heroin by its purity. White drug brings no fever but black drug usually
causes fever because it is not pure. In addition, injection is more rapid, economic and
efficient. Distilled water was aspired into the syringe, then shook to dissolve and
injected into the vein. The cost of a dose of heroin depends on market supply. The
highest price can be as many as 80,000 - 100,000 VN Dong, while normally, it is
40,000 - 50,000 VN Dong/dose (and the lowest is 25,000 - 30,000 VN Dong/dose).
Previously, at drug shooting galleries, drug was already prepared and put in syringe,
and sold to poor drug users. Now, drug users can buy drug and prepare themselves".
(an injecting drug user, male, 40 years old)

The shift from injection to smoking is difficult and very few people can practice it.

"In fact, nobody can shift from injection to smoking, only when the vein can no longer
be used. The shift from injection to smoking is difficult because it is costly and less
efficient. Therefore only the very rich people can maintain the smoke". (an injecting
drug user, male, 33 years old)

     Table 8: Trend of drug use situation in 10 hot communes in Hanoi City.
                                             12/19981                    5/20012
Characteristics                         n                %          n               %
*Sex
- Male                                1172              92,9       873             94,7
- Female                               89                7,1        49              5,3
- Total                               1261              100        906             100
*Education level
- Illiterate                            36               2,9        02              0,3
- Primary (1-5)                        250              19,8       124             17,5
- Secondary I (6-9)                    790              62,7       448             63,4
- Secondary II (10-12)                 167              13,2       131             18,5
- High school/University                18               1,4        02              0,3
- Total                               1261              100        707             100
* Employment
- Employed                               126           10,0           131           14,2
- Unemployed                             863           68,4           516           56,0
- Others                                 272           21,6           275           29,8
- Total                                 1261           100            922           100
* Way of drug use
- Smoking                                260           20,6           104           11,5
- Sniffing                               743           58,9           525           57,9
- Injecting                              202           16,0           327           36,1
- Total                                 1261           100            906           100
(Source:
1
  . Hanoi Social Evil Department, Review Meeting for drug use survey in Hanoi, 8/4/1999)
2
  . Drug use survey in May 2001 at 10 communes: Thanh Xuan nam, Hang Buom, Phuc Tan,
Chuong duong, Nam Dong, Trung phung, Trung liet, Thanh Nhan, Bach Mai, Phuc xa

                                            28
Table 8 shows that the number of drug users has been decreased, which is consistent
with reports from the City Sub-Department for Social Evil Control on drug use
situation in Hanoi. Three main reasons which may explain for the decrease of drug
users as presented in the above table. Firstly, the city has made great efforts to
mobilize the whole society, agencies, mass organizations, schools, and families in
prevention and fighting again drug traffic and drug use. Second, a number of drug
users were sent to treatment centers for drug treatment. The third, the local authority
may do not want to report the new drug users.


Table 9: Characteristics of drug user in the City Drug Treatment Center
                                 in the year 2000.
                        Characteristics                  Frequency           %
1        Sex               Male                                   890            100

2        Age               <20                                     39             4,4
                           20-30                                  589            66,2
                           31-40                                  220            24,7
                           >40                                     42             4,7

3        Marriage          Yes                                    343            38,5
                           No                                     547            61,5

4        Education level   Illiterate                              12             1,3
                           Primary (1-5)                           82             9,2
                           Secondary I (6-9)                      378            42,5
                           Secondary II (10-12)                   331            37,2
                           Vocational school                       26             2,9
                           High school/University                  61             6,8

5        Employment        Employed                               522            58,7
                           Unemployed                             368            41,3

6        Way of drug use   Smoke                                  337            37,9
                           Injection                              553            62,1

7        Duration of drug - <2 years                                1            0,01
         use              - 2-5 years                             742            83,4
                          - >5 years                              147            16,5

8        Law violence      - No                                   220            24,7
                           - Criminal record                      332            37,3
                           - Police record                        338            37,9

9        HIV test          Positive                               270            25,7
                           Negative                               781            74,3

Source: Data from City Drug Treatment Center, Ba Vi, Hanoi, 6/2001.
                                           29
Table 7 shows general characteristics of drug users who have attended the City
Treatment Center for the year 2000. The Drug Treatment Center of Hanoi was
established in 1987 in Cau Buou, then moved to Ba Vi in 1997. There are 45 staff
members, including 4 medical doctors who are working in the center.



3.2.3 Drug use policy in Vietnam


     In January 1993, the National Program on Drug abuse Control was established.
      with following policies and measures: implement anti-drug information and
      education programs; eliminate opium poppy cultivation; strengthen efforts
      against illicit production and trafficking; suppress opium dens and drug
      injection locations; treat drug addict on compulsory basis in accordance with
      existing law using various modalities as appropriate.
     Drug use is considered as a crime as mentioned in
      the penal law, Article 199 (promulgated by the
      National Assembly on December 21, 1999). Everyone
      using illegal drugs of any form, having been warned
      against drug abuse and confined to the compulsory
      rehabilitation center but still continuing to use
      drugs, will be sentenced to imprisonment for three
      months to two years. All recidivists of this crime
      will be sentenced to two-to-five years imprisonment.
     In the year 2000, the Government approved a law for prevention and control
      of drug use
          -   All drug users 18 years or over who attended withdrawal courses at
              family or at community but still use drugs should be confined to the
              compulsory rehabilitation center.
          -   The confinement of drug users in the compulsory rehabilitation center
              will be carried out according to the decision of the Chair of the
              People’s Committee at district level. The time in the rehabilitation
              center will be one to two years.
     The community considers drug use as a social evil, and it must be abolished.
      Although the point of view of people in the community is controversial. Drug
      users are accepted by the community and encouraged to attend treatment
      courses, and helped to return the normal life. The information, education and
      communication activities about the harm of drug use and preventive measures
      for drug use are critical and should be strengthened.




                                         30
In the recent years, illicit production, trafficking and use of narcotic drugs, are
increasing in Vietnam. In January 1993, the National Program on Drug Abuse
Control was established. The Resolution No. 06-CP was launched with following
policies and measures: implement anti-drug information and education programs;
eliminate opium poppy cultivation; strengthen efforts against illicit production and
trafficking; suppress opium dens and drug injection locations; treat drug addict on
compulsory basis in accordance with existing law using various modalities as
appropriate. Depending on the local situation, treatment of addiction can be in the
government or private treatment centers or at home, integrating with job training,
employment of ex-addicts and solution of social problems. Law enforcement is
strengthening to IDUs, FSWs, their clients, drug dealers, brothel (hotel, restaurant)
owners.

Recently, in order to strengthen the fight against drug use, the Government approved a
law for prevention and control of drug use (No. 23/2000/QH10, dated 09/12/2000,
which was promulgated by the National Assembly, Tenth Legislature, 8th Session, on
December 9, 2000.

  Article 3.3: All forms of illegal use of drugs or incitement and encouragement for
   drug abuse are strictly prohibited.

  Article 27: Drug withdrawal in the family or community is obligatory for all drug
   abusers.

  Article 28.1: All drug users 18 years or over who attended withdrawal courses at
   family or at community but still use drugs should be confined to the compulsory
   rehabilitation center.

  Article 28.2: The confinement of drug users in the compulsory rehabilitation center
   will be carried out according to the decision of the Chair of the People’s
   Committee at district level. The time in the rehabilitation center will be one to two
   years.

  Article 28.3: Such drug users who voluntarily demand to have drug withdrawal
   will be admitted to the compulsory rehabilitation center without being considered
   as punished.

In addition, drug use is seen as a crime as mentioned in the penal law, Article 199
(promulgated by the National Assembly on December 21, 1999). Everyone using
illegal drugs of any form, having been warned against drug abuse and confined to the
compulsory rehabilitation center but still continuing to use drugs, will be sentenced to
imprisonment for three months to two years. All recidivists of this crime will be
sentenced to two-to-five years imprisonment.




                                          31
3.2.4 Viewpoint of community to drug users

Viewpoint of authorities.

     Drug use is a social evil, and it must be abolished.

      "Drug users must be strictly controlled, encouraged to abandon their bad habit
      and facilitated to come back to normal life. Drug use is national catastrophe
      that must be controlled on a regular and long term basis" (a representative
      from Commune People's Committee, male 43 years old)

     Public propagation should be strengthened to increase the awareness of the
      people about bad consequences of drug use including HIV transmission within
      the community. It requires the fully active participation of the community in
      the drug control activities.

     The drug users should receive the care of the community.

       " We accept and help them to carry out drug withdrawal at home. Activities
      such as friend-help-friend clubs, HIV/AIDS counseling, cultural and sport
      activities should be established" (a representative from Women's Union, female
      48 years old)

     Drug users are encouraged to attend treatment courses.

      "We never accept drug use. However, given the present situation that drug
      addiction cannot be radically abolished, we must unwillingly tolerate drug
      users. Of course, their family and community also accepted them, help them to
      take care of their health through providing sterile needles and syringes." (a
      representative from District People's Committee, male 43 years old)



Viewpoint of the Police Service

The police never accept drug users. Police agent is deputy chief of the steering
committee for drug control and prevention at the community level. Therefore the
Police Service is playing an important role in the management and promotion of drug
addicts withdrawal.

      " Drug use should be determined in suppressing drug use and never accept it".
      (a representative from Commune Police Service, male 45 years old)

Viewpoint of the Sub-Department for Social Evils Control

     They accept drug users and promote educational activities for drug use and
      HIV/AIDS prevention in the community.

                                          32
     Their duty is to control strictly drug users, encourage drug users to have drug
      withdrawal and help them to return to normal life in collaboration with local
      authorities.

Point of view of the mass organizations

     They participate in controlling strictly drug users, encourage drug users to have
      drug withdrawal and help them to return to normal life in collaboration with
      local authorities.

     The families that have members confined for drug withdrawal need to be
      assisted .

     The information, education and communication activities about the harm of
      drug use and preventive measures for drug use are critical and should be
      strengthened.

Viewpoint of drug users' families

     There are no families tolerating their members to use drug.

     When a member fells into drug addiction, there are two different responses of
      the family:

      + Majority of families assists its member to withdraw in concealing the
      community until they failed.

      + The more active but less frequent attitude is to seek for assistance from
      community organizations and local authority to bring their member into normal
      life as soon as possible.

      "Addiction should not be concealed, rather to open to the public in seeking the
      assistance of friends. Addiction, however, is of different types. If the family
      cannot resolve, the best way is to ask the community for help". (a father of a
      drug user)

"I am so angry with him, but I have pity on him. Now, with my old age, I must be
resigned." (a mother of a drug user)

      Most of families want their children having jobs. "If he can have some job
      during 8 hours daily to avoid idleness, even with low income" (a father of a
      drug user)

 Their additive children are treated.

      "It is better to have drug withdrawn at home for new drug users, and at remote
      areas for long time for drug users who have long drug use duration." (a father
      of a drug user)
                                          33
 All drug traffic sites should be eliminated

            "Our family has a child who is drug addictive. We can not abandon him.
      Drug is the cause of evil that must be radically abolished, particularly at
      present, "crazy drug" widely used by young people." (a father of a drug user)

     Needles and syringes should be provided to prevent HIV transmission but the
      used needles and syringes must be disposed properly for avoiding harmful
      effect for others.

            "Syringe and needle must be suitably disposed. It is harmful if they
      share needles. But if they have in abundance, they will throw them
      everywhere".(a mother of a drug user)

     The community should not discriminate against drug users

      "Family members should not be too serious to drug user. I often advice my
      young brother, but never abandon him, because he is anyhow a human being"
      (a brother of a drug user).

Viewpoint of people in the community

     The point of view of people in the community is controversial. Majority do not
      accept drug use. But somebody have shown their tolerance with them and have
      collaborated with local authorities in assisting drug users back to normal life.

Needs of IDUs

     Most of IDUs want to be treated for drug addiction and have a job.

      " We wish to have some remedies that can help us to withdraw the drug,
      making us free from torture..." (a injecting drug user, male, 40 years old).

      "We need a job. However, it is still hardly to find a job for a normal person. I
      want to be independent from family. Having a job, one can either be free from
      complex or have some income." (a injecting drug user, male, 20 years old).




                                         34
3.3 Risk behaviors


3.3.1 Drug use practice of drug users in Hanoi


   Drug injection becomes more common because of its low cost and high
    efficient in comparison with other routes.
   In the past opium was common, many drug users have combined opium with
    such narcotic drugs as Dolargan or Valium. At shooting galleries, drugs were
    available, and in many places, drug solution was prepared and ready for
    injection. The rate of needle sharing was very high and considered as
    "normal", especially when sharing with an intimate friend or with everyone
    looking healthy.
   In the year 2000, the rate of needle sharing during last 6 months in Hanoi was
    31.9%. The lending used syringes/needles during the last month was also
    rather high (25.6%). The main reason for sharing was that drug users have no
    time and conditions to sterilize their injecting instruments or to use
    disposable syringes because of police sweeping.
   The rate of drug injection among street FSWs was rather high. Injection
    partners of injecting FSWs were mainly job fellows, boy friends or husband.
    The rate of needles and syringes sharing was very high.
   The proportion of drug users who reported properly cleaning their syringe
    represent was 35.7%, (Report of HIV/AIDS BSS in Vietnam, 2000).
   Drug users are changing their behavior. Many of them are injecting at home
    instead at shooting galleries, because it was cheaper and safer.




Results of focus group discussions show that drug injection becomes more common
because of its low cost and high efficient in comparison with other routes. In the past,
opium was common, many drug users have combined opium with such narcotic drugs
as Dolargan or Valium. At shooting galleries, drugs were available, and in many
places, drug solution was prepared and ready for injection. In the past, the rate of
needle sharing was very high and considered as "normal", especially when sharing
with an intimate friend or with everyone looking healthy. The rate of needle sharing
during last 6 months in Hanoi was 31.9%. The lending used syringes/needles during
the last month was also rather high (25.6%). The proportion of drug users who
reported properly cleaning their syringe represent was 35.7%. Most (87.8%) of IDUs
have good knowledge on HIV prevention) (Source: National AIDS Bureau/FHI.
Report of HIV/AIDS BSS in Vietnam, 2000).



                                          35
Methodology of Behavioral Surveillance Survey (BSS) in Vietnam 2000

In 2000, five provinces were selected for inclusion in the first round of behavioral
surveillance in Vietnam including Hai Phong and Hanoi in the northern region, Da
Nang in the central part of the country, and Can Tho and Hochiminh City in the
south. These provinces were chosen for the following reasons: 1). They represent
diverse ecological areas of Vietnam; 2) Reported HIV prevalence data indicates that
they are regions with high risk for disease spread; 3) There are currently many
HIV/AIDS interventions in all five areas; and, 4) The capacity of the provincial
government staffs and networks within the selected populations was strong enough to
enable the study teams to successfully implement the survey. For the purposes of this
study, IDUs were defined as persons who used non-medically prescribed drugs by
injecting in the past six months. A list of registered IDUs was provided by the
Provincial Sub-Departments for Social Evils Control and formed the basis for the
IDU sampling framework. Thirty clusters were selected from the list using a
probability proportional to size (PPS) sampling methodology. From each of the
selected clusters, index cases were chosen based on sub-categories or networks of
IDUs that were identified during the mapping exercise. Each index case was ask by
the interviewer to identify other injection drug users whom he believed would be
willing to participate in the study, a recruitment technique known as “snowballing”.
The anonymity of all newly identified drug users was strictly maintained, and
whenever possible IDUs were interviewed by IDU peer educators.

There is no special belief related to needle sharing. The main reason for sharing was
that drug users have no time and conditions to sterilize their injecting instruments or to
use disposable syringes because of police sweeping. Most drug users have known that
such drug available at shooting galleries was not safe, as drug was drawn from a
contaminated container with non-sterile syringe. They all think that drug injection is
harmful, but there is no supported environment for them to change high risk
behaviors. Nevertheless, recent studies show that drug users are changing their
behavior. Many of them are injecting at home instead at shooting galleries, because it
was cheaper and safer.

"Until the year 1998, the rate of sharing of needles/syringes or drug pot was very
high... 30-40 drug users shared a vacuum flask cover of water to rinse their syringes.
Now, disposable syringe is available with low price, about 500-1000 Dong/unit, they
can afford it. Now needle sharing becomes rare and only in particular circumstances
such as at night. In the other hand, drug users are afraid of blood mixture in sharing
the needle, that can eventually lead to fever" (a injecting drug user, male, 46 years
old).

" In the last few years the rate of sharing syringes and needles was more than 50%.
But now it can occur at sometimes, especially when crisis appears without any clean
needle. For example, sharing can occur occasionally at night, when pharmacies are
closed or crisis suddenly appears There is no willing to use needles and syringes "".
(a injecting drug user, male, 26 years old).
                                           36
"At present, the use of drug filled syringes or the share of drugs is rare. It was
common only in previous time. The common pot is suitable only to opium use. Now
heroin use is more common and everybody can buy and prepare themselves the
dose..." (a injecting drug user, male, 33 years old).

"It is widely believed among drug users that sharing drug and blood mixture can
create fever, so this practice is rarely occurred." (a injecting drug user, male, 39 years
old).

Interventions in the last few years can explain for the low rate of sharing needles and
syringes among IDUs in Hanoi. IEC activities were strongly developed. Disposable
syringes and needles were widely commercialized at pharmacies. In addition, there
were programs for provision of syringes and needles by peer educators together with
peer education. It results in considerable reduction of sharing of syringes and needles,
and frequency of injection..

Results from a survey among street children (< 18 years old) (n = 324) far from family
have shown that :

      The majority of street children were coming from economically difficult
       families (75%). Their main jobs are shoe polishing (35.2%), newspaper selling,
       and peddler (32.7%).

      30% of street children smoke and 78.5% drink beer, only 1.6% has reported
       drug use. However, 42.7% street children say that they have seen their friends
       have used drug.

(Source: Nguyen tran Hien et al. Assessment of situational and behavioral risks for
HIV/AIDS among Hanoi street children, April 2001. Unpublished paper.)

"I have seen many street children as me using drugs (about 30 - 50%); among them,
20-40% practice drug injection. They used to inject at deserted area and shared
needles and syringes. I have even seen a roaming mother and her son are both drug
addictive" (a street child, male 17 years old)

" Drug use among street children has a tendency to increase. The main reason for that
was lack of management of the family, so they are readily seduced and controlled by
elder street children" (A member of the Committee for Management and Protection of
Children, Hoan Kiem district)

A cross sectional study among FSWs in Hanoi was conducted in the period June-
September 2000 among 400 FSWs in a rehabilitation center. Table 10 presents the
injecting practices of the FSWs in the study. Nearly one third reported that they had
ever injected in the last six months. Among those who injected in the last six months,
22.6 % had started injecting at an age under 20 years and 48.7% between the ages of
20 and 24. More than two thirds had been injected within the last two years. The main
drug used for injecting was heroin (90.4%). Two thirds of injecting FSWs reported that
                                           37
they injected at least 2 times per day. Many (62.5%) had reused or borrowed
contaminated needles and syringes from other IDUs in the last six months and only
11.8% reported that they always cleaned needles and syringes when they reused or
borrowed contaminated needles and syringes in the last six months. Among injecting
FSWs, 47.6% reported that they had injected outside Hanoi in the last 12 months, and
among them, 29.1% said that they had shared injecting equipment in that other place.
  Table     10: Injecting practices of FSWs in Hanoi City in
                              2000
Injecting practices                        Frequency          Percentage
Ever drug injecting (n=394)                   115                  29.2
Age   for  the first     drug
injection (n=115)
- <20                                           26                   22.6
- 20-24                                         56                   48.7
- 25-29                                         24                   20.9
- >=30                                           9                    7.8
Duration     of     injecting
(yrs.) (n=111)
- <2                                            80                   72.1
- 3-4                                           22                   19.8
>=5                                              9                    8.1
Types of drugs used
- Opium (n=113)                                 43                   38.1
- Heroin (n=115)                               104                   90.4
- Amphetamine (n=111)                            4                    3.6
Frequency of injecting per
day (n=115)
- <=1                                           40                   34.8
- 2-3                                           58                   50.4
->=3                                            17                   14.8
Frequency      of     reusing
needles and syringes in the
last six months (n=112)
- Always                                         7                    6.3
- Most of the time                               5                    4.5
- Sometime                                      52                   46.4
- Quite few                                      6                    5.4
- No                                            42                   37.5
Always cleaning needles and
syringes (n=102)                                12                   11.8
Frequency      of     lending
needles     and      syringes
(n=108)
- Always                                         2                    1.9
- Most of the time                               5                    4.6
- Sometime                                      41                   38.0
- Quite few                                     10                    9.3
- No                                            50                   46.3
Injecting outside of Hanoi
City   in   the   last   year                   51                   47.6
(n=107)
Reusing      needles      and
syringes outside of Hanoi                       15                   29.4
                                        38
City   in        the      last       year
(n=51)
(Source: Nguyen tran Hien et al. HIV infection among female sex workers in Hanoi, Vietnam,
2000: relationship between HIV seropositivity, characteristics of sex work and injection drug
use.(unpublished paper)

"The rate of drug injection among street FSWs was 6 out of 10, while the rate among
karaoke bar girls was only 1 out of 10 (a street prostitute, ranging after the 05
Circular).

Injection partners of injecting FSWs were mainly job fellows, boy friends or husband.
"If there is no regret in giving the body, why do regret in sharing syringes with
boyfriend or darling". FSWs may get HIV infection mainly from their boyfriends or
lovers, who were drug users.

             Table 11: Drug injection behaviors of drug users in Hanoi

        Characteristics                                                   %       Sample
                                                                                   size
 1.   Drug injection            - less than 1 time/day                    31.4    n 360
      frequency during          - 1 time/day                              27.8
      the last month            - 2-3 times/day                           40.8
                                - 4 times and more/day                     0.0
 2    Reusing of used           - Always                                     0    n=357
      syringes /needles         - Most of times                            2.0
      during the last 6         - Half of times                            0.8
      month                     - Some times                              29.1
                                - Never                                   68.1
 3.   Reusing of used           - Always                                     0    n 360
      syringes /needles         - Most of times                            1.9
      during the last           - Half of times                            1.1
      month                     - Some times                              19.2
                                - Never                                   77.8
 4    Lending used              - Always                                   0.6    n 360
      syringes/needles          - Most of times                            2.2
      during the last           - Half of times                            1.9
      month                     - Some times                              20.8
                                - Never                                   74.4
 5    Frequency of              - Always                                  17.6     n 85
      cleaning used             - Most of times                           20.0
      syringe/needles           - Half of times                           4.7
      during the last           - Some times                              37.6
      month                     - Never                                   20.0
 6    Way of cleaning           - By cold water                           25.7    n109
      used                      - By hot water                            55.0
      syringes/needles          - Boiling                                 23.8
                                - By antiseptic chemical                   1.8
                                - By ethanol                              10.1
                                             39
                              -   Other                                0.0

Source: National AIDS Bureau. Report of HIV/AIDS BSS in Vietnam, 2000. Hanoi-5/2001




3.3.2 Sexual practice of drug users in Hanoi


   The mean of sexual partners of IDUs in the last 12 months in Hanoi was 1.7
    FSWs, 0.2 non-regular and 0.4 regular sexual partners
   The condom use in the last sex among IDUs was 82.4% with FSWs, 41.2%
    with non-regular and 25.4% with regular sexual partners.
   However, consistent use of condom in the last 12 months was rather low,
    27% with FSWs, 21.6% with non-regular and 14.8% with regular sexual
    partners.
   1.6% of IDUs reported that they have ever had a STD


According to BSS results in Hanoi in the year 2000, the mean of sexual partners of
IDUs in the last 12 months in Hanoi was 1.7 FSWs, 0.2 non-regular and 0.4 regular
sexual partners (Source: National AIDS Bureau. Report of HIV/AIDS BSS in Vietnam,
2000. Hanoi-5/2001)

Most of IDUs consider that when addicted, the need for sex is not high. Some IDUs
thought that drug and sex are antagonist.

"At the beginning of drug use, sexual need has been strong, but when one has been
seriously addicted, the need for sex disappears, ... once a month..." (a injecting drug
user, male, 26 years old).

"Once addicted, seeking for drug is hard enough, so there is no time to think about
sex. However, when needed, one can have sex with prostitute. At that moment, condom
use is often neglected because it is not carried with one or hardly to buy at once." (a
injecting drug user, male, 30 years old).

"When crisis occurs, without drugs I cannot accept any sexual partner, and drug is
not able to enhance sexuality". (a injecting drug user, female, 32 years old).

"For the IDUs who were young and unmarried, if they need sex, they often look for a
FSW. The sexual practice of oral-genital or anal-genital was not common. However,
condom is rarely used and one often hesitates to go to pharmacy for buying condoms.
Male homosexual practice is not frequent in Hanoi, and approach to these subjects
was very difficult." (a injecting drug user, male, 28 years old).


                                          40
The condom use in the last sex with FSWs among IDUs 82.4% in Hanoi, while it was
59.5% in Ho chi Minh City, 69% in Da nang, and 57.1% in Can tho. The condom use
in the last sex with non-regular and regular sexual partners was lower (41.2% and
25.4% respectively. , Source: National AIDS Bureau. Report of HIV/AIDS BSS in
Vietnam, 2000. Hanoi-5/2001. It may be the reason of HIV transmission to their lover
or husband.


                Table 12: Sexual behaviors of drug users in Hanoi

      Characteristics                                               %         Sample
                                                                               size
 1    Number of sex    - Regular partner                              0.4         131
      partner during   - Non-regular partner                          0.2          29
      the last year    - Sex worker                                   1.7          85
 2    Using condom     - Regular partner                             25.4         134
      in the last sex  - Non-regular partner                         41.2          34
                       - Sex worker                                  82.4          85
 3    Frequency of     - Every time                                  14.8     n 135
      condom use       - Most of the time                            11.1
      when have sex    - Sometimes                                   31.1
      with regular sex - Never                                       43.0
      partner during   - Do not remember                              1.6
      the last 12
      months
 4    Frequency of     - Every time                                  21.2     n 33
      condom use       - Most of the time                            15.2
      when have sex    - Sometimes                                   21.2
      with non         - Never                                       39.4
      regular sex
      partner during   - Do not remember                                0.0
      the last 12
      months
 5    Frequency of     - Every time                                  27.9     n 86
      condom use       - Most of the time                            51.2
      when have sex    - Sometimes                                   10.5
      with sex worker - Never                                        10.5
      during the last  - Do not remember                              0.0
      12 months
 6    Seeking          - Go to government health services            80.0      n=5
      behavior for     - Go to private health services               80.0
      STD treatment    - Go to healer                                 0.0
      for the last     - self treatment at home                      20.0
      STD episode      - Tell sexual partner about the disease        0.0
                       - Stop having sex                             80.0
                                         41
                            -Use condom                                    20.0
 8      Knowledge of        Right knowledge                                87.8    n=358
        HIV prevention      Wrong knowledge                                 5.3    n=358




        Characteristics                                                  %        Sample
                                                                                    size
 9      HIV Testing         - Have had HIV test                            46.9    n=358
                            - Have got HIV test result                     81.5
                            - Having volunteer HIV test                    38.4
                            - Have got HIV test result among
                            volunteers                                     93.7
 10     Receive HIV         - Condom                                       19.8    n=358
        prevention          - Syringes/needles                             52.5
        support during      - Leaflets                                     74.0
        the last 6          - Advice from peer group                       31.8
        months              - Others                                        0.0


Source: National AIDS Bureau. Report of HIV/AIDS BSS in Vietnam, 2000. Hanoi-5/2001

3.4. Health consequences of drug use.

3.4.1 HIV/AIDS situation in Vietnam

                               HIV/AIDS situation in Vietnam

      The first HIV infection was reported in December 1990 in Ho chi Minh City (HCMC).
        As 12 December, 2001, 42,365 HIV-positive cases were reported in all 61 provinces in
        Vietnam. The proportion of HIV infection among all reported HIV-positive cases
        were 60.2% for IDUs, 3.9% for FSWs, 2.1% for STD patients. High proportion
        of HIV infection for IDUs among all reported infection has influenced the
        distribution of reported HIV cases by age and sex. HIV infection has so far
        occurred mainly among males, who account for 84,7% of total reported
        infections. Infection has spread primarily among young adults: 50.9% were 20-
        29 years old, 23.0% were 30-39. As 12 December 10, 2001, 6,343 AIDS cases
        were reported, among them 2,663 died of AIDS.

      The results of HIV sentinel surveillance show that
       overall, Vietnam is in the concentrated stage of an
       HIV epidemic, when HIV prevalence is more than 5% in
       high-risk behaviour populations, and less than 1% in
       the general population. In many provinces in Vietnam,
       HIV prevalence rates were still relatively low among
                               42
       FSWs, STD patients, prenatal care attendees and army
       conscripts.

      Vietnam’s HIV epidemic is predominantly and still
       rapidly increasing among IDUs in many provinces in
HIV testing system

HIV testing has been started in Vietnam since 1988. It was conducted, co-ordinated
and it’s results were reported to the regional Pasteur Institutes and then to the National
Institute of Hygiene and Epidemiology in Hanoi by provincial centers for preventive
medicine. HIV testing is mandatory for IDUs, FSWs, blood donors and prisoners,
whereas it remains voluntary for other groups. Blood samples were collected in
rehabilitation centers for IDUs and FSWs, and in public STD clinics.

HIV case report

The first HIV infection was reported in December 1990 in Ho chi Minh City
(HCMC). In 1991 no HIV infection was reported. Only 11 HIV infection were
reported in 1992, but in 1993 there was an outbreak of HIV infection occurred among
IDUs in the central and the southern parts of the country, especially in Nha trang and
HCMC. The number of reported HIV infected cases increased annually. As 12
December, 2001, 42,365 HIV-positive cases were reported in all 61 provinces in
Vietnam. (Figure 7) However, it is worth noticing that this reported data does not
reflect the actual situation and trends of HIV transmission in Vietnam.

The number of provinces reporting HIV/AIDS infected cases is increasing every year.
This number increased from 1 province in 1990, to 7 provinces in 1992, 30 provinces
in 1993 and 57 provinces in 1997. In 1998, HIV was found in all the 61 provinces in
Vietnam.




                                           43
           Figure 7: Annually HIV case reports in Vietnam
(Source: AIDS Division, Ministry of Health, as 12 December 12, 2001)




        Figure 8: HIV infection by risk categories in Vietnam
 (Source: AIDS Division, Ministry of Health, as 12 December, 2001)



                                44
The distribution of reported HIV/AIDS by risk exposure category is shown in Figure
8. The proportion of HIV infection among all reported HIV-positive cases were 60.2%
for IDUs, 3.9% for FSWs, 2.1% for STD patients. However, it is noted that there has
been an annual change in the proportion of each risk exposure category of HIV
reported cases. Out of total number of newly reported cases every year, the HIV
proportion of IDUs has reduced from 87% in 1993 to 51.5% in 1996. But this
proportion is increasing again in the past few years in parallel with increase of drug
use. (Figure 9).


         100
         90
         80
         70
         60
     %




         50
         40                                                                   IDUs

         30                                                                   FSWs
         20
         10
          0                                                                   0
                  93



                          94



                                  95



                                          96



                                                   97



                                                           98



                                                                   99



                                                                           -0
               19



                       19



                               19



                                       19



                                                19



                                                        19



                                                                19



                                                                         ct
                                                                        O




                                               YEAR



                        Figure 9: Trend of HIV risk categories in Vietnam
                 (Source: AIDS Division, Ministry of Health, as of May 10, 2001)




                                                  45
                   Figure 10: HIV infection by gender in Vietnam
         (Source: AIDS Division, Ministry of Health, as 12 December, 2001)

High proportion of HIV infection for IDUs among all reported infection has
influenced the distribution of reported HIV cases by age and sex. HIV infection has so
far occurred mainly among males, who account for 84,7%% of total reported
infections. (Figure 10). For the most part, infection has spread primarily among young
adults: 50.9% are 20-29 years old, 23% are 30-39, and 12.7% are 11.540 and 49 years
old (Figure 11). In the beginning of the epidemic, HIV was found mainly in the 30-39
years old groups. Since the past two years, HIV infections were shifted towards the
20-29 years old.




                 Figure 11: HIV infection by age groups in Vietnam
         (Source: AIDS Division, Ministry of Health, as 12 December, 2001)

                                         46
AIDS case report

As 12 December 2001, 6,343 AIDS cases were reported, among them 3,478 died of
AIDS. The WHO definition of AIDS was applied to diagnose AIDS patients. The
increase of AIDS cases (Figure 12) did not match the situation of reported HIV
infections and the natural history of HIV infection progression. Referring to reported
HIV infections, the reported AIDS cases suggested that the progression from a
symptomatic HIV infection to AIDS was relatively fast, and the HIV epidemic might
have occurred and widespread sooner in Vietnam, even before the year 1990 when the
first HIV case was detected. Clinical symptoms of AIDS in Vietnam mainly are
opportunistic infections such as TB, zona, and diarrhea. The distribution of AIDS
cases by sex, age groups and risk categories was similar to HIV infection. (Figure 13-
15).




                  Figure 12: Trend of AIDS reported cases in Vietnam
           (Source: AIDS Division, Ministry of Health, as December 12, 2001)


                              UK
                              21%




                                                                           Male
                                                                           64%

                 Female
                  15%




                     Figure 13: AIDS cases by sex in Vietnam
                                         47
          (Source: AIDS Division, Ministry of Health, as 12 December, 2001)



    30
%
    25

    20

    15

    10

     5

     0
          <13         13-19   20-9      30-39     40-49      >50       UK
                                     AGE GROUP



                      Figure 14: AIDS cases by age in Vietnam
          (Source: AIDS Division, Ministry of Health, as 12 December, 2001)



          UK                                                                  IDU
         34%                                                                  40%




Other
 5%




                Perinatal
                                                Sexual
                  1%
                                                 20%



                 Figure 15: AIDS cases by risk categories in Vietnam
          (Source: AIDS Division, Ministry of Health, as 12 December, 2001)


                                         48
HIV Sentinel surveillance

In the first quarter of 1994, HIV sentinel surveillance was implemented in eight
provinces. The program was expanded to four other provinces in 1995 and eight other
provinces in 1996, giving a current total of 20 sentinel provinces of a total of 61
provinces in Vietnam. The provinces selected for the HIV sentinel surveillance
program were those with a high risk for HIV transmission in different geographical
areas of varying ecological types throughout the country, from the north to the central
and the south, including the highlands, delta, and coast regions. In all provinces, most
of the individuals surveyed were living in urban areas.

Sentinel populations: The following sentinel populations were selected in each
sentinel province:

 Patients attending public STD clinics. Only minority of STD patients (about 10%
  in the estimation of STD experts) come to public STD clinics. The other patients
  visit private practitioners.

 IDUs living in drug treatment centers. Most of these drug users were arrested by
  the police or forced to come by their families.

 FSWs who were detained in rehabilitation centers, or bar/massage girls who are
  known to work in prostitution. All FSWs in the rehabilitation centers were arrested
  by the police.

 Women attending family planning centers or clinics for prenatal care, delivery or
  abortion.

 Tuberculosis (TB) patients with all clinical types of TB in the TB
  clinics/Departments or TB centers.

 Army conscripts receiving military training at the sentinel province.

Sentinel sites: For each sentinel population in each sentinel province the one to two of
the largest suitable sites were selected. For STD patients, these were hospitals or STD
clinics; for IDUs centers for drug treatment; for FSWs rehabilitation centres or
massage parlours; for TB patients, hospitals, TB clinics or TB centers; for pregnant
women obstetric care hospitals/departments or family planning centres, and for army
conscripts, military establishments.

Sampling: At the beginning of the program, the sample size for each sentinel
population in each site was 400 for IDUs, FSWs, STD patients and TB patients, and
800 for antenatal women and army conscripts. The cross-sectional surveys were
repeated every six months for IDUs, FSWs and STD patients, and every year for
antenatal women, army conscripts and TB patients. Samples were consecutively
collected until the sample size was reached. If after 8 weeks the sample size was not
reached, still the sampling could be continued to reach the sample size. Unlinked
                                          49
anonymous methods were recommended in order to minimise the participation bias
which may make data unusable for surveillance purposes. However, in practice due to
the request of local authorities to know who are infected, in many provinces, the
results of HIV testing are linked to individual identities. HIV testing results were
committed by health workers to keep in confidentiality for counselling, management
and care. After three years of the program, the sample size of each population in each
survey was reduced from 400 to 200 for the two-month periods to avoid duplicated
sampling of the same person and to adapt the local situation. Except for army
conscripts, blood collection was a routine procedure. Demographic information about
age, sex, residence, risk behaviour, and the date of serum collection and testing, were
collected from all individuals tested. A standard form for data collection was
developed.

HIV testing strategy: The World Health Organisation (WHO) recommendations about
a HIV testing strategy [13] were followed. For the purpose of surveillance, strategy II
was used. This strategy implies that a sample is considered positive if it is positive for
both screening tests: agglutination (SERODIA HIV, Fujirebio Inc., Japan) and ELISA
(GENELAVIA MIX, Sanofi Pasteur Diagnotistics, France, or VIRONOSTICA,
Organon, the Netherlands).

Results of the HIV sentinel surveillance by the end 2000 show that:

 HIV infection primarily associated with injecting drug use. There was an increased
  tendency of HIV prevalence in al high risk behavior groups: among IDUs from
  18,3% in 1994 to 22.1% in 2000; among FSWs from 0,6% in 1994 to 4.3% in
  2000 ; and among STDs patients from 0,5% in 1994 to 1,3% in 2000

 Until 1996, the prevalence of HIV infection among IDUs was high in the southern
  provinces, but since 1997 there have been explosive increases in HIV prevalence
  among IDUs in many northern provinces. It is clear that in Vietnam HIV infection
  is predominantly and rapidly being transmitted among injecting drug users,
  through sharing needles and syringes with an aggregated rate of 22,1% in 2000. In
  1999, the HIV prevalence was very high in many provinces such as in Binh Dinh
  (75,9%), Nha Trang (71,7%); Quang ninh (65,9%), Hai phong (60,4%), Da Nang
  (51,2%), Vung tau (43,5%), Dac lac (41%), and HCMC (33,5%). By the regions,
  HIV prevalence among IDUs in the central was higher than that in other regions of
  the country.

 Recently, there was a fast increase of HIV prevalence among FSWs in HCMC
  (from 3.1% in 1998 to 15.9% in 1999, 18.1% in 2000) and in Ha noi (from 3.7% in
  1998 to 6.5% in 1999, and 10% in 2000). The high prevalence of drug injecting
  among FSWs may explain this increase. A study results in Hanoi show that about
  30% FSWs are using drug.( Nguyen tran Hien et al., un-published paper)

 Sexual transmission of HIV in the south appears to be more extensive than in the
  north. In the southern provinces, especially in the Mekong Delta area and at the
                                           50
   border with Cambodia, the HIV prevalence among FSWs was higher than in the
   northern provinces. In 1999, it reached 12.5% in An giang and 3.5% in Kien giang,
   and 4.2% in Can tho. HIV prevalence among patients with STDs remained quite
   low, ranging from zero to 6% in 1999 with an aggregated rate of 1.6%. It was
   more than 1% in many provinces

 HIV prevalence rates among prenatal attendees and army conscripts were still
  rather low, ranging from zero in many provinces to less than 1% in others, with an
  aggregated rate of 0.2% and 0.9% in 2000 respectively. (Except in Quang ninh,
  HIV prevalence among army conscripts was rather high (5%), because of high
  prevalence of both injecting drug use and HIV infection among injecting drug
  users). Higher HIV prevalence rates among antenatal women and army conscripts
  were found in the southern provinces, where also has higher prevalence rates
  among FSWs and STD patients.

 Vietnam is in the concentrated stage of HIV epidemic. It means that HIV
  prevalence is more than 5% in high-risk behaviour populations (especially more
  than 20% among IDUs), and lower than 1% in the general population.

(Source: Report of Sub-Committee of HIV Surveillance, MOH, 2001)



                                       25
                  HIV prevalence (%)




                                       20

                                       15

                                       10

                                       5

                                       0
                                            94   95    96    97    98   99   00-
                                                            YEAR



                Figure 16:HIV prevalence trend among IDUs in Vietnam
           (Source: Report of Sub-Committee of HIV Surveillance, MOH, 2001)




                                                      51
                     5
                                                        3.8




HIV prevalence (%)
                                                                4.3
                     4

                     3

                     2
                         0.6
                     1

                     0
                         94    95   96        97   98   99    00-
                                          YEAR




                                         52
     Figure 17: HIV prevalence trend among FSWs in Vietnam
(Source: Report of Sub-Committee of HIV Surveillance, MOH, 2001)




                              2.0
     HIV prevalence (%)




                              1.5

                              1.0

                              0.5

                              0.0
                                                     94        95        96     97     98    99    00-
                                                                               YEAR


Figure 18: HIV prevalence trend among STD's patients in Vietnam
(Source: Report of Sub-Committee of HIV Surveillance, MOH, 2001)



                                               1.8
                                               1.6
                          HIV prevalence (%)




                                               1.4
                                               1.2
                                               1.0
                                               0.8
                                               0.6
                                               0.4
                                               0.2
                                               0.0
                                                          94        95         96      97     98         99   00-
                                                                                      YEAR



  Figure 19: HIV prevalence trend among TB patients in Vietnam
(Source: Report of Sub-Committee of HIV Surveillance, MOH, 2001)




                                                                          54
                                0.25
           HIV prevalence (%)
                                0.20

                                0.15

                                0.10

                                0.05

                                0.00
                                            94    95    96        97    98   99   00-
                                                                 YEAR


Figure 20: HIV prevalence trend among pregnant women in Vietnam
  (Source: Report of Sub-Committee of HIV Surveillance, MOH, 2001)




                          1.0
HIV Prevalence (%)




                          0.8

                          0.6

                          0.4

                          0.2

                          0.0
                                       94        95    96         97    98   99   00-
                                                                 YEAR


       Figure 21: HIV prevalence trend among army recruits in Vietnam
       (Source: Report of Sub-Committee of HIV Surveillance, MOH, 2001)




                                                            55
3.4.2 HIV/AIDS situation in Hanoi


                             HIV/AIDS situation in Hanoi

  The first HIV case was reported in Hanoi in 1993. The cumulative HIV reported
   cases was 3,022 by 31 December 2000. Majority of HIV reported cases were
   injecting drug users (76%). 264 AIDS cases were reported, among them 152
   already died of AIDS .
  Majority of HIV infected people are male. HIV infection occurred mainly at the
   age group of 20-29, accounts for 77.9%. The urban districts which reported high
   number of HIV cases were Gia lam, Dong Da, Ba dinh, Tay ho, Hoan kiem, Hai
   ba trung.

                Table 13: Estimation of HIV infection in 1999 in Hanoi .


       Populations                                      Low estimates   High estimates
 1     Drug user                                               1,0400            13,000
 2     Sex worker                                                 760             5,000
 3     STD patient                                              1,087             7,609
 4     HIV prevalence ratio among drug user (%)                 17.50             17.50
 5     HIV prevalence ratio among sex worker (%)                10.00             10.00
 6     HIV prevalence ratio among STD patient (%)                3.00              3.00
 7     HIV prevalence ratio among pregnant woman (%)             0.50              0.50
 8     HIV infection number among drug user                     1,820            2,2275
 9     HIV infection number among sex worker                       76               500
 10    HIV infection number among STD patient                      33               228
 11    HIV infection number among male aged 15-49               3,833             3,833
 12    HIV infection number among female aged 15-49             3,861             3,861
 13    HIV infection number among children                         46                46


 (Source: Estimation and projection in Vietnam, 1999-2005, Ministry of Health 12/2000)




                                              56
The first HIV case was reported in Hanoi in 1993. There was a small increase in the
period 1994-1997. But since in 1998, number of reported cases increased rapidly
about 40 to 600 every year, made the cumulative reported cases of 3,022 by 31
December 2001. But it should be noted that it does not reflect the real situation in
Hanoi. Estimation of HIV infection in 1999 in Hanoi is
presented in Table 12. Majority of HIV infected people are male. By age
group, HIV infection occurs mainly at the age group of 20-29, accounts for 77.9%.
264 AIDS cases were reported, among them 152 already died of AIDS (57.6%).

                                3500
                                                                                                3022
                                3000
           HIV reported cases




                                2500
                                                 New   Cummu.
                                2000                                                  1739
                                1500                                                         1283
                                                                              1082
                                1000
                                                                             683     657
                                500                                    399
                                                                     337
                                       11   45   813   1932   3062
                                  0
                                       93

                                            94

                                                 95

                                                       96

                                                               97

                                                                     98

                                                                             99

                                                                                     00'


                                                              Year                            31/12/01'




        Figure 22: Annually HIV reported cases in Hanoi, by 31 December 2001
                            (Source: Hanoi AIDS Bureau)

By 30 June 2001, urban districts which reported high number of HIV cases were Gia
lam, Dong Da, Ba dinh, Tay ho, Hoan kiem, Hai ba trung. Other districts such as Soc
son and Thanh tri reported the lowest number of HIV infection.




                                                            57
                    600                                                                                                     600

                    500
                          450
        HIV cases   400           372
                                         319
                    300                                   280
                                                                 203 200
                    200
                                                  153                                     142
                                                                                 114               116
                    100
                                                                                                            54
                                                                                                                    19
                     0




                                                                                                   T/XUAN



                                                                                                                    s.SON
                          G.LAM




                                                                                 T.LIEM

                                                                                          C.GIAY
                                  D.DA




                                                          H.BA




                                                                                                                            UK
                                                                 H.KIEM
                                                  D.ANH




                                                                                                            T.TRI
                                                                          T.HO
                                         B.DINH




    Figure 23: HIV cases reported by districts in Hanoi, by 31 December 2001
                         (Source: Hanoi AIDS Bureau)




                                            Other
    AIDS supected                           20.8%
        1.0%

 STDs
 1.6%




                                                                                                     IDUs
        FSWs                                                                                        73.4%
        4.2%




Figure 24: HIV infection by risk categories in Hanoi,, by 31 DEcember 2001
                       (Source: Hanoi AIDS Bureau)




                                                                 58
Distribution of HIV infection is presented in Figure 21. Majority is injecting drug
users (76%).

Results of HIV sentinel surveillance show that HIV prevalence increased among high
risk behavior groups, especially among injecting drug users and commercial sex
workers in the years 1999 and 2000 (Figure 22). HIV prevalence among pregnant
women and army recruits is very low, less than 1%.



                               20
                               18
                               16                        STDs
          HIV prevalence (%)




                               14                        FSWs
                               12                        IDUs
                               10
                               8
                               6
                               4
                               2
                               0
                                    94   95   96         97     98   99   '00
                                                        YEAR




  Figure 25: Trend of HIV prevalence among high-risk behaviour groups resulted from the
                     sentinel surveillance in Hanoi during 1994-2000
                               (Source: Hanoi AIDS Bureau)




                                                   59
                 300                                                            264


                 250

                 200
     HIV cases



                 150
                                                                      84
                 100
                                                  24          34
                 50           6      12

                  0
                       1996       1997       1998          1999    2000    31/12/01'
                                                    Year




Figure 26: Cumulated AIDS reported cases by years in Hanoi, by 31 December 2001
                        (Source: Hanoi AIDS Bureau)




                                         Female
                                           8%




                                                            Male
                                                            92%




                 Figure 27:AIDS cases by genders in Hanoi, by 31 December 2001
                                 (Source: Hanoi AIDS Bureau)




                                                    60
       60


       50


       40


    % 30


       20


       10


        0
            13-19   20-29   30-39        40-49   50+      KR
                             AGE GROUP




 Figure 28: AIDS cases by age groups in Hanoi, by 31 December 2001
                   (Source: Hanoi AIDS Bureau)




                    UK                           Sexual
                    4%                            7%




                    IDUs
                    89%




Figure 29: AIDS cases by risk categories in Hanoi, by 31 December 2001
                    (Source: Hanoi AIDS Bureau)


                                    61
Estimation of HIV infection in 1999 in Hanoi is presented
in Table 12. Methods of estimation and projection is
described as following.

Information available at the end of 1999, such as results
of HIV sentinel surveillance in 20 sentinel provinces,
HIV testing for case finding and AIDS cases, reported and
estimated numbers of drug users (IDU), female sex workers
(FMW), and sexually transmitted disease (STD) patients,
and population sizes at age 15-49 was collected.

Estimation of HIV infected cases was calculated using the
following formula:.

       No. HIV infections = Population size x HIV
  seroprevalence rate

HIV sero-prevalence rates were estimated    based    on    the
results of HIV surveillance program.

Number of injecting drug users (IDUs) was estimated based
on the reports of the City Department for Social Evils
Control. Three possible numbers were used to prepare
projections:

 The lowest number of IDUs was estimated by multiplying
  the reported number of drug users by the proportion
  injecting

 The highest number of IDUs was estimates by of the City
  Department for Social Evils Control.

Numbers of female sex workers (FSW) were estimated using
data from the same sources as those for estimation of
IDUs. It was also estimated in two scenarios:

 The lowest number of FSWs was the number reported by
  City Department for Social Evils Control

 The highest number of FSWs was estimates          by    City
  Department for Social Evils Control

Numbers of STD patients were estimated based on the
official reported data of the City Center of Dermatology
and Venereology


                            62
   - The lowest number of STDs was estimated by using the
   reported number.

   - The   highest  number   of  STDs   was   estimated  by
     multiplying the reported number by 7,     based on the
     opinion of STD experts that only 15% of STD patients
     went to public STD clinics for treatment.

Data on the population aged 15-49 in all provinces in
1999 was provided by the General Statistics Department
(14).

HIV cases was estimated for each population. The detailed calculation of HIV estimated
numbers was as follows:

 Number of HIV infections in each high risk population
  (IDUs, FSWs, STD patients) = estimated seroprevalence
  rate x estimated population size

 Number of HIV infected males = (estimated number of
  males aged 15-49 x seroprevalence among antenatal
  women) + estimated number of infected IDUs + 22% of HIV
  infected STD patients

 Number of HIV infected females = (estimated number of
  females aged 15-49 x seroprevalence among antenatal
  women) + number of HIV infected FSWs + 78% of HIV
  infected STD patients

 Number of HIV infected infants = number of infected
  females aged 15-49 x birth rate (1.8%) x assumed
  prenatal transmission rate (30%)



3.4.3 Viral hepatitis

Globally, hepatitis C virus infection (HCV) is a common consequence in injecting
drug users. Though social impact of HCV infection is less serious than HIV infection,
however, with considerable cases and long duration of illness followed by frequent
complications, the disease can have serious consequences for the health and economy
of drug users. HCV antibodies are present at 60-70% of IDUs, in some areas, this rate
can be as high as 80-100%.

There was little information about prevalence of HCV and STDs among IDUs in
Hanoi.


                                         63
The prevalence of HCV infection among IDUs in Hanoi was of 61% (61/100) (Pham
Song et al, 1994.). However, a study in HCMC shows that the prevalence of HCV
infection among IDUs in HCMC was excessively high, as presented in the following
table (La thi Nhan et al.)

 Table 14: Prevalence of HBV and HCV infections among IDUs at the Thu duc
                   Drug Treatment Center, HCMC, 1995.

  No. of        HBsAg         HBeAg        Anti-HBc      Anti-HBs      Anti-HCV
  cases

    108            41            7            102            37           105

               (37.96%)       6.48%)       (94.44%)       34.25%)       (97.22%)

(Source: Prevalence of HBV and HCV infections among at the Thu duc Drug
Treatment Center, HCMC, Vietnam Journal of Medical Practice, 1996. No 6)



In general, IDUs have limited knowledge about HCV and HBV infections, which are
consequences of injecting drug use.

3.4.4 Drug shock

According to the City Department for Social Evil Control, in Hanoi, in the year 2000,
there were about 100 deaths due to drug shock.

"Drug shock occurs, mainly among IDUs with incomplete withdrawal, who reused
drug with uncontrollable dosage. It can lead to death".(an injecting drug user, male
29 years old)

3.4.5 Sexually transmitted diseases

According to HIV/AIDS BSS report in Vietnam 2000, the reported STDs among
IDUs in Hanoi were low, 1.6%, while it was 3.7% in HCMC. The majority of them
(80%) seek medical care at public health centers when experiencing genital
symptoms. All of them have fully used the described drugs.

3.4.6 Community opinions concerning drug use consequences

Consequences on economy:

In opinions of local authorities, the consequences of drug addiction are considerable,
causing not only depletion of family but also increasing economic burdens of the state
with large expenses for drug control activities and loss of young working force.

Consequences on family, community, and society
                                         64
 The family of drug users is economically depleted and its members are persistently
anxious, and suffer from the community discrimination. The community is also in
anxiety about the threat of drug use among their children, and about the criminals
caused by drug users.

Consequences on living condition and life-style of drug users

The majority of drug users are living in poverty and doubtfulness of the community.
Their life-style has been changed since they are addicted. They often sleep in daytime
and carry out their activities essentially at night. Their unique concern is how to gain
money in order to satisfy their drug addiction. Sometimes they become ventured and
lazy.




3.5 Interventions among drug use population

3.5.1 Interventions among drug use population in Vietnam


               Interventions among drug use population in Vietnam

  Variety of drug abuse treatment methods are used such as cool bathing, massage,
   acupuncture, traditional and tonic medicine, psychological therapy, and labor
   therapy (mainly psychological treatment). A pilot methadone program was in
   small scale in Hanoi.
  Drug abuse treatment in community in some pilot urban communes with the same
   methods in the treatment centers.
  IEC on HIV/AIDS prevention by the outreach teams using ex-users as peer
   educators, providing care and support to HIV infected people, through activities of
   self-help groups, Coffee shops, Green shops, clubs, counseling centers....
  Pilot programs of needle and syringes exchange providing alcohol and bleach were
   conducted in Hanoi, Ho chi Minh city and other provinces.
  Pilot programs of providing alcohol and bleach were conducted. It was not
   accepted by IDUs and drug dealers because it was less inconvenient than water.




Strategy for HIV infection control among drug users in Vietnam


                                          65
A national strategic plan for the prevention and control of HIV/AIDS has been in place
since 1994. The major strategies and priority interventions are:
 promotion of safer sexual behaviors, including the use of condoms
 provision of condom
 promotion of STD health seeking behavior
 ensuring safe and efficient STD care service
 implementation of an education program for injecting drug abusers
 ensuring safe blood transfusion
 preparation of comprehensive care for HIV infected persons and their families.

Relating drug abuse issue, the National AIDS Committee has also set up the policy that
the HIV/AIDS problem should be considered separately without linking it to reduction
of injecting drug use and prostitution. Because injecting drug use is illegal and
inaccessible, Non-Governmental Organizations should be encouraged to establish
networks of social workers and peer educators for education about safe drug use and safe
sex probably in collaboration with treatment centers. It can be noted that political and
technical authorities in Viet Nam are highly conscious of the HIV threat in their
populations.

It can be noted that political and technical authorities in Viet Nam are highly conscious
of the drug use and strengthening the law for so-called social evils. In some provinces a
more targeted approach has been initiated to reach those who are engaged in high risk
behaviors by recruiting ex-user as peer educator. Harm reduction approach was
implemented in Hanoi and HCMC and now is expanding into many other provinces. In
general, there are different intervention programs with different approaches:

 There are different drug treatment methods with different approaches: cool
  washing, massage, acupuncture, traditional and tonic prescriptions, neuroleptic and
  physical therapy (mainly psychotropic treatment). A pilot program of methadone
  therapy is also developed at Hanoi. There are 55 centers for drug treatment centers
  all over the country. However, results have been limited. The percentage of drug
  users who reported drug abstinence was low, less than 10% in many provinces. A
  pilot methadone program was in small scale in Hanoi. Drug abuse treatment in
  community in some pilot urban communes with the same methods in the treatment
  centers.
 IEC on HIV/AIDS prevention by the outreach teams using ex-users as peer
  educators, providing care and support to HIV infected people, through activities of
  self-help groups, Coffee shops, Green shops, clubs, counseling centers....
 Pilot programs of needle and syringes exchange providing alcohol and bleach were
  conducted.
 Pilot programs of providing alcohol and bleach were conducted. It was not accepted
  by IDUs and drug dealers because it is less inconvenient than water.

Following were intervention projects for HIV prevention among IDUs in Vietnam:

                                           66
 A small-scale two-year research project (1995-1997), supported by WHO on harm
  reduction activities for HIV prevention among IDUs in Hanoi and Ho chi Minh City,
  including peer education and supports for behavior changes,.
 A pilot HIV prevention outreach and peer education project in HCMC supported by
  The Save the Children Fund since 1991, targeted high risk behavior population,
  including IDUs.
 An HIV/AIDS outreach prevention project in Da nang City supported by World
  Vision since 1992.
 A comprehensive HIV prevention program supported by German Government
  Technical Cooperation (GTZ) in three provinces: Lao cai, Hanoi, Ninh Binh,
  including peer education and counseling (1995-1997)
 A UNDCP project supports outreach efforts in drug abuse and HIV prevention in 5
  provinces: Hanoi, Quang ninh, Lang son, Thai nguyen and Nghe an, 1998-2000.



3.5.2 Interventions among drug use population in Hanoi


               Interventions among drug use population in Hanoi

   The police collaborates with local authorities and mass organizations in
     arresting and eliminating shooting galleries..
   Most of communes of 12 districts have conducted regularly IEC about drug
     use prevention, safer behaviors for HIV prevention, sympathy, no
     discrimination with HIV infected people via mass media and other channels
     such as local newspaper, radio, broadcasting, posters, banderoles, leaflets,
     clubs for social evil prevention, contest, art performance, meetings,
     discussions ect.
  Drug treatment activities:
    - Three mechanisms for drug treatment are developed: Voluntary treatment at
    home with the assistance of local authorities and mass organizations; voluntary
    treatment in treatment centers and compulsory treatment in treatment centers.
    - Variety of drug treatment methods are implemented such as cool bath,
    massage, acupuncture, traditional and tonic remedies, neuroleptic and physical
    therapies. A pilot program of methadone therapy has been piloted.
    - Some communes have created a job for post-treatment drug users, for
    example motorcycle washing and repair, commodity carrying...
  Harm reduction activities for HIV prevention
    - Pilot program for exchange of needles and syringes, and bleach supply.
    - Glass syringes with instruction for use have been supplied to IDUs.
    - Peer education groups has distributed thousands of leaflets and
    syringes/needles, and condoms to drug users.
  Program for management, care and counseling of HIV infected people:
     - Peer educator are giving are and support to HIV/AIDS people through
                                           67
     activities of "friend help friend" group, "green coffee", "counseling center"etc.
     - The program for management, care and counseling has covered 70% of HIV
     infected people.
  Although there were controversial opinions about harm reduction intervention,
    majority of community agrees with peer education and the distribution of
    needles, syringes, bleach and condoms to IDUs.
Activities for prevention of drug use and drug criminality

     The police collaborates with local authorities and mass organizations in
      arresting and eliminating shooting galleries. Drug users will be registered and
      confined to treatment centers. Drug criminals can be brought to trial at a mobile
      court. People in the community are encouraged to inform against drug use and
      drug criminality. A hot line has been established to receive and process
      information about drug use and drug criminality.
     Regular surveys about drug use in the community was conducted, especially in
      the hot communes/places of drug use and to develop suitable control measures.
     During three previous years, the municipal police has revealed 5,228 of drug
      affairs, 9,317 drug use and traffickers. 25.21 kg and 46,517 small packs of
      heroin, 232.77 kg + 4,527 pills + 16.3 liters of opium, 1.26 kg of marijuana,
      17,870 tablets and ampoules of addictive drugs, 567 pills of amphetamine were
      seized
     In 1998, 13 drug-related hot sites have been identified in an attempt to
      eliminate. Seven sites have been destroyed: Gia lam, Duc giang, Yen vien,
      Trung liet, Nam dong Phuc xa, Thanh nhan. The remainder hot sites have no
      overt illegal activities as previously.


Information-Education and Communication (IEC) activities

IEC activities was carried out with a variety of contents and methods.

     Most of communes of all 12 districts conduct regularly IEC activities about
      drug use prevention, safer behavior, HIV prevention, sympathy, no
      discrimination with HIV infected people via mass media and other channels
      such as local newspaper, radio, broadcasting, posters, banderoles, leaflets,
                                          68
    clubs for social evil prevention, contest, art performance, meetings, discussions
    ect.
   On the basis of longitudinal management, all public offices at district level
    have issued appropriate directives about educational activities to grass-root
    levels in order to transfer information about HIV infection prevention to the
    community in general, and to drug use population, in particular.
   During the year 2000, about 70,000 leaflets, 800 educational video tapes
    entitled "Stop drug addiction catastrophe", and 2000 publications entitled
    "Drug catastrophe, identification and action" have been published.
   Two reportage films have been produced to participate to national film gala on
    criminal and social evil control. Both two films have been awarded.
   Awarding conferences have been organized to honour meritorious non-drug
    addiction communities and schools in 1999 and the movement for 2000 have
    been launched to achieve and maintain non-drug use units. All communes
    commit for "two NO and one YES" (that is no new drug use, no shooting
    galleries, and yes for good withdrawal activity).
   The Sub-Department of Social evil Control have collaborated with the Center
    for Community Mobilization for AIDS prevention in training on HIV
    prevention for staff of the City Drug Treatment Center. In addition it's staff
    come to communities, agencies, schools to talk about drug and HIV prevention.




                                       69
                                                Table 15: Activities for drug treatment and Support for drug users
                                          (Source: Review Meeting of City Sub-Department for Social Evil Control, 2000


No     District        Number                           Increased number                                   Decreased number
                       of drug
                        users                   New      New       Relapse     Move   Return     Total     Stop    Move      Move   Death
                                  Total         drug    detected   of drug      in     from                drug   to other    out
                                                                                               decreased
                       estimated increased      users                use              center                use    center,
                                                                                                                   prison
1    Hai          Ba       1684           263      21        44         73       52      82         428    160       142      115     11
     Trung
2    Dong da               1790           109       2        48         17        6      36         179      75        81      15       8
3    Hoan kiem             1275           133       1        30         28        5      67         233      75      111       31     16
4    Ba dinh               1129           144      23        51         19        9      54         207      83        72      38     14
5    Thanh Xuan             553           175      10        39         47       21      66         131      48        44      34       7
6    Tay Ho                 514           118       3        30         34       12      39          91      39        32       7       3
7    Cau giay               444            59       4         2         37        2      26          66      40        12      11       3
8    Gia Lam                869           440      24       117        228       12      59         192    116         49      23       4
9    Thanh Tri              456            36       4        25            3      0        4         80      50        15       9       3
10   Tu Liem                282           112       7        38         41        7      12          99      37        36      25       1
11   Dong Anh               342            34       1        14            6      2      11          47      34         6       5       2
12   Soc son                130            22       0        13            7      0        2         15       5        10       0       0
     Total                 9468       1645        100       451        540      128     458        1768    762       610      313     72
       Source: Report on drug prevention and control activities. Review Meeting of City Drug Steering Committee, 2000.



                                                                                 70
                                                   Table 16: Drug treatment result


                                                            Places for drug treatment
                        Received                                                                                  Received
           No. of                             At home           Drug treatment                Others                                Received a job
  Year                  treatment                                                                             vocational training
         drug users                                                 center
                        n        %        n             %          n          %          n              %        n         %         n         %
 1998       9040      2553     28.24     1946      76.22         470         18.4       137            7.10     379       14.85     905      35.45
 1999       9284      2647     28.51     1214      45.86         937         35.4       496        18.74        784       29.62     1507     56.93
 2000       9468      2412     25.48     1038      43.03         1124        46.6       250        10.36        650       26.95     1200     49.75


Source: Report for three years implementing the decision of drug prevention program of the Prime Minister, 1999-2000. Hanoi People’s
Committee




                                                                        71
                                                                                   72


Drug treatment activities

     Surveys on drug use situation of drug users has been performed annually. In
      addition, review has been done every 6 months on variation of drug use in
      order to develop appropriate measures for treatment and management of drug
      users.
     The Counseling Center for drug use prevention of the Sub-Department for
      Social Evil Control has provided knowledge about drug prevention and post-
      treatment counseling, measures for HIV/AIDS prevention, counseling for drug
      users in other treatment centers.
     Three mechanisms for drug treatment are developed:
      - Voluntary treatment at home with the assistance of local authorities and mass
      organizations.
      - Voluntary treatment in treatment centers.
      - Compulsory treatment.
     Variety of drug treatment methods are implemented such as cool bath,
      massage, acupuncture, traditional and tonic remedies, neuroleptic and physical
      therapies (with special emphasis on neuroleptic therapy). A pilot program of
      methadone therapy has been piloted.
     During the year 2000, the city has offered all types of treatment for 2,229 drug
      users :
      + Compulsory and voluntary treatment in city treatment centers : 1,247 drug
      users
              - at the City Treatment Center : 1,107
              - at Social Assistance Center II : 116
              - at Tan trieu Education and Vocational Training Center: 24
      + Treatment at home with assistance of local authority and mass organizations:
      797
      + Other forms (self-management at home, at private health clinics): 271
     The capacity for drug compulsory treatment at City Treatment Center was
      improved over the years. The planned occupancy rate increased from 47%
      (1998) to 94% (1999) and 98% (2000). The duration of treatment increased
      from 3 to 6 months (in April, 1999) and to 12 months (in 2001). Four treatment
      centers are now available in Hanoi :
              - City Treatment Center with a capacity for 500 persons
              - Youth Educational Center with capacity for 300 persons
              - Social Assistance Center II, reserved for female drug users, with
              capacity for 150 persons.
              - Tan trieu Education and Vocational Training Center with capacity for
              50 persons, reserved for voluntary drug users.
     The model for treatment at home with assistance of local authorities and mass
      organizations is applied to mild and recent drug users, following a 5-stage
      process during 3 years continuously. After 2 years of piloting, this model has
      been considered as efficient model with encouraging outcome.




                                         72
                                                                                        73


     Treatment center have applied such therapeutic procedures as guided by the
      Circular N 31 joined by Ministry of Labor-Invalid and Social Affairs and
      Ministry of Health /TT-BLDTBXH-Y TE), including :
             + Treating the crises, detoxification, and health restoration
             + Personality rehabilitation, behavioral change associated with cultural
             activities.
             + Job orientation and vocational training, and productive labor.
             + Re-integration with community and family

Post-treatment management

     Job training and creation for preventing relapse were conducted. For three
      years, 1,831 persons have received job training and 3,612 persons have
      obtained a job. Some localities have created a job for post-treatment drug users,
      for example motorcycle washing and repair, commodity carrying... However,
      these activities have limited results, because they were not interesting in these
      jobs, and because of bad impression of the community on these drug users.
     The responsibility of families in management of their members to prevent
      relapse was enhanced.
     The City is improving the drug treatment, oriented toward enhancement of
      treatment quality, simplification of formality in voluntary treatment and
      development of new centers. Investment for other centers have been in course.

Difficulties and constraints of drug control programs

Based on the RAR data, the difficulties and constraints of drug control programs as
following:

     Though the control of criminality and drug use has been in progress, they were
      still not driven back. Illegal activities of drug criminals have been more
      complicated and dangerous.

     Drug treatment effect is still limited. The number of drug users in Hanoi still
      increases and the target to reduction by 40% at the end of 2000 as compared
      with 1998 (with absolute number of drug users 3000) is not obtained. Annual
      number of drug users treated have been small (representing only about 20% of
      total of drug users). The treatment duration is still short (3 - 6 months) with
      high rate of relapse. The general rate of relapse after 3 years is about 91 percent
      and the target of annual reduction of relapse by 10% is not reached. There are
      also many difficulties in selecting suitable places for the establishment of new
      treatment centers and in creating job for drug users after treatment.

     The IEC activities is not deep enough, not regular and still in short duration.




                                          73
                                                                                        74


      There are few creative models to attract young people for participating in the
       creation of safe environment without drug. The management sometimes is
       neglected.

      The policy for assisting drug users is still limited, with small scale and focusing
       mainly on poor families.

      The City Drug Treatment Center are facing with many difficulties:

       - Many HIV positive cases were not counseled.

       - Lack of conditions and facilities for better care for HIV infected people. The
       suspected cases were to refer to hospitals.

       - Lack of counseling for HIV infected individuals, as well for drug users.

- No vocation-oriented program for subjects after discharged or community re-
     integration

       - Lack of trained staff while the number of drug users is increasing.

       - Lack of labor protection devices for staff who expose daily to drug users.
       Remuneration is also very low.

        (Source: Results from group discussion and in-depth interview among staff of
       the City Treatment Center)



Harm reduction activities for HIV prevention

 Activities for supporting behavior changes

    - Pilot program for exchange of needles and syringes, and bleach supply. The
    program for alcohol and bleach supply has been developed but not accepted by
    drug users, because of more inconvenient than simple water use.

-   During 1999, 10,000 glass syringes with instruction for use and condoms have
    been provided to IDUs.

-   The peer education group          has   distributed   thousands    of   leaflets   and
    syringes/needles to drug users.

 Program for management, care and counseling of HIV infected people:

    - Peer educator are giving are and support to HIV/AIDS people through activities
    of "friend help friend" group, "green coffee", "counseling center", etc.




                                            74
                                                                                   75


    - The program for management, care and counseling has covered 70% of HIV
    infected people.

Point of view of community about harm reduction interventions.

A survey on the point of view of community authorities about harm reduction
approach show the following findings. Majority of community authorities agree with
peer education and said that these activities are conformed to the law for control of
prostitution and drug use, and contribute to reduction of social evils. They accepted
the distribution of needles and syringes and antiseptic drugs to injecting drug users
(IDUs). They also agree to propagation activities on condom use. They think that
condom use can enhance the control of HIV infection.

(Source : Report from investigation on current HIV infection and measures for
HIV/AIDS Control in Hanoi, December, 1999)

However, there are controversy opinions about the distribution of needles/syringes
among IDUs. In general, the provision of needles/syringes are not accepted by
families and community because it is considered encourage drug use. Some families
have driven away the peer educators when they come to provide needles and syringes.
"Our son has already gave up drug use, will you encourage him to be addicted
again?"

In general, everyone consider the harm reduction interventions are necessary, and
relevant to the work of peer educators. Some opinions insist that the needles/syringes
distribution should aim at families of drug users.

"Currently, we are doing effective interventions. We are implementing several
activities: provision of needles/syringes through the peer net work, counseling for
drug users, organizing and facilitating "Friend help friend" clubs and clubs of ex-
users. These activities should be maintained, though lack of finance is a challenging
problem".

"The family is a good manager of drug users. So, the provision of sterile needles
should be directed to family".




                                         75
                                 Table 17 : Intervention activities in 12 districts of Hanoi by March 2001


                                                               Interventions
                      Syringe    Condom         Peer          Peer         Counseling    Job creation        Friend help
         District    provision   provision    education     education                                           friend
                                               among       among IDU
                                                FSW
       Ba dinh           +           +            -          + (3x3)*          +              +                   -
       Hoan kiem         +           +         + (6x1)          -              +              -                   -
       Hai ba            +           +            -          + (3x1)           +              -                   -
       Dong da           +           +            -          + (3x1)           +              -               + (7x1)
       Tay ho            +           +         + (6x1)      + (10x1)           +              -               + (15x1)
       Cau giay          +           +            -          + (5x4)           +              +               + (5x1)
       Thanh xuan        -           -            -          + (3x1)           -              -                   -
       Gia lam           +           +         + (6x1)      + (12x1)           -              -               + (12x1)
       Dong anh          +           +            -          + (3x1)           +              -                   -
       Tu liem           +           +            -          + (3x1)           +              +                   -
       Thanh tri         +           +            -          + (3x1)           -              -                   -
       Soc son           +           +            -          + (3x1)           +              -               + (5x1)


+/- : There was/no intervention activity
*: Number of peer educators x number of groups
 (Source: Group discussions with district AIDS program officers, 3/2001)



                                                                    76
Difficulties and constraints of HIV/AIDS interventions

Based on the RAR data, the RAR team found the difficulties and constraints of
HIV/AIDS interventions as following:

     Lack of close cooperation between related ministries and sectors, leading to
      discrepancy of policy among these organizations.
     The viewpoint considering that drug use, prostitution, and HIV/AIDS are
      closely related to social evils will result in difficulty to approach drug users and
      prostitutes to perform health education and support behavior change for them.
      They can hardly change their behavior without a supportive environment.
     EIC activities has focused more on public communication but not directed to
      high risk behavior groups, such as IDUs and FSWs, both in forms and in
      contents
     Activities aiming at harm reduction have been conducted as pilot study in small
      scale without systematic monitoring and evaluation. Such harm reduction
      activities as provision of syringes, needles, and condoms were implemented in
      some communes, with an irregular small target group. There was no HIV/AIDS
      coffee shop or similar settings where drug users can come for HIV information
      and supports for behavior change in Hanoi.
     The number of peer educators was too small for approaching high-risk
      populations, that are relatively considerable in Hanoi. In addition, there was
      lack of financial resources, together with the monotonousness of IEC materials,
      for efficient activities of peer education groups. Peer educators have not been
      trained regularly on communication and counseling skills. They have not
      received efficient assistance from authorities and communities.
     Harm reduction activities for HIV infection were in pilot stage, with small
      scale and low coverage. These activities, being irregular and poorly
      maintainable, have focused rather in giving information than in providing
      materials for behavioral change, such as needles, syringes and condoms.
     There was lack of services for HIV infected or high-risk individuals.
     Families of drug users and HIV infected persons have not fully collaborated in
      the harm reduction interventions.
     Peer education were lacking of financial resources, sympathy and assistance of
      local authorities, communities and families of HIV infected persons or drug
      users. They also lacked of materials and means of communication.
     The management of HIV infected persons was very difficult because of their
      hesitance for contact, their constant mobility and the lack of drugs for
      HIV/AIDS treatment.
     Lack of health workers who are specialized in HIV prevention and control
      because they are often concurrently in charge of different health programs.
     There were a large number of HIV infected people at the City Treatment
      Center. but there was lack of conditions for HIV infection control there.




                                          77
   There was lack of community-based programs and experiences with
    appropriate skills and methods for approaching high-risk individuals, such as
    drug users and their sexual partners, sex workers and their clients.




                                     78
4. CONCLUSION AND RECOMMENDATIONS


1. There was still an increase of drug users in Hanoi although less than previous
   years.
 The proportion of injecting among drug users has been increased considerably.
   The main cause of the shift from smoking to injecting was the higher cost-
   effectiveness of injecting.
 There is predominance of young male among drug users. Female drug users have
   been also increased, especially among street FSWs.
 The main drug currently in use is heroin

Recommendations:

In order to reduce the number of drug users following activities should be
strengthened:
      IEC activities on harmful effect of drug, and drug use prevention among
       general population, especially among young people
      Drug treatment with all types at treatment centers or in the community together
       with and job creation for drug users.
      establishment and support for the activities of post-treatment clubs or ex-drug
       user

2. Although IDUs in Hanoi have rather good knowledge about preventive measures
   of HIV infection they are still practicing high risk behaviors:
 The rate of sharing needles and syringes in the last 6 months among IDUs in 2000
   was 31.9%
 The condom use in the last sex among IDUs was 82.4% with FSWs, 41.2% with
   non-regular and 25.4% with regular sexual partners. However, consistent use of
   condom in the last 12 months was rather low, 27% with FSWs, 21.6% with non-
   regular and 14.8% with regular sexual partners.
 HIV prevalence was increasing rapidly among IDUs: 17.5% among IDUs and 10%
   among FSWs in the year 2000.

Recommendations:

In-depth IEC with appropriate contents and methods for
IDUs through the activities of peer education groups,
should be implemented. The activities of peer educators
should be strengthened both in quantity and quality as
following:
 Increase number of peer educators in districts where HIV prevalence and risk
  behaviors is high. The criteria for selection of peer educator should be flexible,
  emphasizing the effectiveness of activities of peer educators.
 More training on knowledge and communication skills should be provided.


                                         79
 Experience exchanges among peer education groups between districts inside and
  outside provinces should be strengthened.
 IEC package, including update and new diverse IEC material, condoms, needles
  and syringes, and travel support (such as bicycles or motorcycles in certain
  districts) should be provided.
 Activities of peer education groups should be changed for better planning,
  supervising, and with different attractive measures. The peer educators should be
  empowered, with the leadership of the group leader for more active involvement.
 More provision/supply of condoms and needles and syringes is required.
 Some more financial support for daily outreach work and weekly meeting is
  needed.
 Income/incentives for peer educators should be increased by different sources: job
  opportunity raising (coffee shop, motorcycle washing...), community contribution,
  and integration of different financial sources...
 Health care services for high risk people and those need it, especially for peer
  educators should be provided, for example free health insurance, low cost primary
  health care...

More services such as voluntary HIV counseling and
testing, STI treatment, care for HIV infected people, and
for high risk and vulnerable people should be
established.

3. There were many interventions on HIV prevention among drug users. However
   activities aiming at minimizing the harms for HIV prevention, assisting in
   behavioral change, such as syringes, alcohol, and bleach supply through peer
   education groups were still at small scale. The approach to drug users for IEC
   activities and support became more difficult because of enforcement of new law on
   drug use. The view-point of local authorities, sectors, and mass organizations
   about HIV prevention among IDUs was controversial.

Recommendations:

A high commitment of authorities at all levels is required to mobilize the participation
of the whole society in the HIV prevention and control program:
 Strengthen the close collaboration of sectors, mass organizations, agencies and
    authorities in HIV prevention and control activities.
 Improve the knowledge and awareness of local authorities and community about
    harm reduction measures and the role of pee education.
 Maintain and replicate intervention models in the family and community,
    integrating with other health education programs
 More active community participation in supporting activities of peer education
    groups, including finance, job opportunities, meeting rooms and other facilities

4. There was lack of information about viral hepatitis B and C infections among
   IDUs in Hanoi.

                                          80
Recommendations:

 Information about viral hepatitis and other health consequences should be
  collected. Prevention and care services for health consequences should be
  establishes.




                                        81
5.3. Planning for activities

                                                     Table 18: Planning for activities

        Activities                                   Responsible                         Time schedule   Feasibility
1       Meeting for planning of activities, resource - City AIDS Bureau                     7/2001
        mobilization, assignment of responsibilities - Faculty of Public health

2       Meeting with community for discussion about       - City AIDS Bureau                7/2001       Require time and work to
        the role of harm reduction approach and of peer   - Faculty of Public health                     activate masses
        education                                         - GTZ Organization
3       Mobilize community and plan for establishment     - City AIDS Bureau                7/2001       Require time and work to
        of peer education groups, available resources,    - Faculty of Public health                     activate masses
        mechanism for implementation, monitoring and      - GTZ Organization
        evaluation
4       Training peer education groups on HIV          - City AIDS Bureau                   7/2001
        prevention and communication and counseling    - Faculty of Public health
        skills                                         - GTZ Organization
5       Establish counseling sites for drug users to   - City AIDS Bureau                   7/2001       Training for consultant
        reduce harm consequences of drug use.          - Faculty of Public health                        and finance to maintain the
                                                       - GTZ Organization                                activities
        Establish the meeting points for drug users - City AIDS Bureau
        where they can exchange and improve their - GTZ Organization
        knowledge and skills for HIV prevention.
6       To improve knowledge, skill and to support - City AIDS Bureau                       7/2001       Training for consultant
        technically for HIV prevention and care of HIV - Faculty of Public health                        and finance to maintain the
        infected people at the City Treatment Center.  - GTZ Organization                                activities



                                                                      82
Activities as results of RAR in the period July-December 2001:

The following harm reduction activities were implemented with the technical and
financial support of German-Vietnam Technical Collaboration:

 Training activities
  - Organized 3 training courses about basic knowledge on HIV and
     communication skills for 57 peer educators and 12 supervisors of IDUs and
     FSW peer education groups and "Fiend help friend" groups.
  - Organized 3 training courses for 70 staff of counseling services
  - Organized a training course for 10 HIV infected IDUs about income raise and
     vocation skills
 Support for activities of peer educators: All peer educators were provided support
  means such as IEC materials, bags, caps, leaflets, condoms, needles and syringes,.
 Activities of peer educators were supervised and supported through more regular
  meetings.
 A counseling system with 11 counseling offices was set up. However it has not
  been attracted by clients due incoverniences from both clients and counselors.
 A intervention model for raising income of IDUs was implemented in a commune




                                         83
                                                        Annex 1: Information sources

           Source                                  Data                                                        Comments
City Police Service              Drug use and drug trafficking situation in the           Focus more on law enforcement, detecting and seizing
                                  city                                                               drug trafficking/shooting galleries
                                 Drug policy
                                 Drug hot spots

City Sub-Department for          Report on drug use situation, trends                    Data collected from communes by its system from
Social Evil Control.             Report on drug treatment                                 central to grassroots level
                                 Drug prevention program                                 It miss the drug users from other communes/provinces
                                 Survey on drug use in Hanoi                             There may be reporting bias (underreporting)
City Drug Treatment Center,      Report on almost compulsory treatment for               It is the biggest treatment center for the city
Ba Vi, Hanoi,                     drug users                                              Received mainly compulsory treatment and drug users
                                 Types of treatment                                       who injected for longer duration
                                 HIV prevalence
National AIDS Standing           Report of HIV/AIDS BSS in Vietnam, 2000).               BSS started in 2000 in five provinces, rather
Bureau                           Know ledge, sexual and injecting risk                    representative data on HIV risk behaviors, repeated
                                  behaviors of IDUs only                                   every year, there may be selection bias, mainly among
                                 Policy and strategies for HIV/AIDS                       street IDUs
                                  prevention, intersectoral collaboration and
                                  participation
AIDS Division, Ministry of       HIV/AIDS situation in Vietnam                           Data only about reported cases of HIV/AIDS
Health                           Estimation and projection in Vietnam, 1999-             HIV/AIDS intervention in the health sector only
                                  2005,                                                   estimation and projection is revised every 2-3 years
                                 HIV/AIDS prevention activities in the health
                                  sector

                                                                     84
                                                     Annex 1: Information sources

             Source                                Data                                                Comments
Sub-Committee of HIV             Data on HIV prevalence, and trends among       Data from sentinel surveillance program among sentinel
Surveillance, National                specific populations in Vietnam            populations, sentinel sites and 20 sentinel provinces
Institute of Hygiene and                                                        Low preventative data due to selection bias
Epidemiology

Hanoi City AIDS Bureau        HIV/AIDS situation in Hanoi                      Data reported from communes and district health service
                              HIV prevalence among specific populations        Each commune in the city, there is a Communal
                              HIV/AIDS prevention activities in the city        Committee for HIV/AIDS prevention and control
Mass organization and family Qualitative data about:                            Qualitative data only
of drug users                 Drug use situation and trends                    Data collected though in-depth interview and focus
                              Policy and Interventions for drug and             group discussions
                                HIV/AIDS prevention                             controversial opinion about drug use and harm reduction
                              Attitude to drug use and HIV/AIDS                 interventions

Drug users                      Drug use situation/mapping of drug use in      Data collected though in-depth interview and focus
                                 the city                                        group discussions
                                Drug use practice                              Data may be biased due to selection bias. Only drug
                                Risk behaviors of drug users                    users who have regular contacts with peer educators
                                Drug and HIV/AIDS policy and                    could be reached.
                                 interventions
                                Health consequences of drug use
                                mapping




                                                                   85
         Annex 2: Leading causes of morbidity and mortality in Vietnam in 2000


                                        Cases/
                   Diseases            100,000                   Diseases          Deaths/
                                                                                   100,000

 1. Pneumonia                          361.76         Pneumonia                     2.12
 2. Acute pharyngitis and acute        345.42         Intracerebral hemorrhage      2.00
     tonsillitis
 3. Acute bronchitis and acute         333.36         intra-cerebral injury         1.97
     bronchiolitis
 4. Diarrhoea and                      236.38         Heart failure                 1.20
     gastroenteritis of presumed
     infectious origin
 5. Influenza                          232.48         Respiratory tuberculosis      1.14




 6. Other injuries of specified,       164.82         Transport accident            1.09
     unspecified and multy body
     regions
 7. Respiratory tuberculosis           162.32         Stroke, not specified as      1.02
                                                      hemorrhage or infarction
 8. Transport accident                 160.45         Slow fetal growth, fetal      0.96
                                                      malnutrition and disorders
                                                      related to short gestation
                                                      and low birth weight
 9. Primary hypertension               133.08         Myocardial infectus           0.92
 10. Other complications               129.89         Suicides                      0.89
     pregnancy and delivery

Source: Health statistics, Ministry of Health, 2000



                                             86
            Annex 3: Leading causes of morbidity and mortality in Hanoi in 1998


              Diseases                Cases   Cases/             Diseases           Deaths   Death/
                                              100000                                         100000

1. Acute bronchitis and acute         7 074   300.1    Pneumonia                     60       2.5
   bronchiolitis
2. Pneumonia                          4 986   211.5    intracerebral                 44       1.8
                                                       hemorrhage
3. Dengue fever                       4 674   198.3    Slow fetal growth, fetal      38       1.6
                                                       malnutrition           and
                                                       disorders related to short
                                                       gestation and low birth
                                                       weight
4. Diarrhea and gastroenteritis       3 596   152.6    Benign neoplasm               32       1.3
   of    presumed        infectious
   origin
5. Diseases of appendix               1 763    74.8    Respiratory tuberculosis      23       0.9
6. Gastric and duodenal ulcer         1 669    70.8    Measles                       12       0.5
7. Mental     and      behavioral     1 646    69.8    intrauterine hypoxia and       8       0.3
   disorder                                            birth asphyxia
8. Cataract         and      other    1 646    69.8    Burns                          8       0.3
   disorders of lens
9. Asthma                             1 546    65.6    Malignant neoplasm of          6       0.2
                                                       trachea, bronchus and
                                                       lung
10. Primary hypertension              1 209    51.3    Malignant neoplasm of          5       0.2
                                                       liver and bile ducts
 Source: Health statistics, Hanoi Health Service, 1998




                                               87
Annex 4:
  CHECKLIST FOR FOCUS GROUP DISCUSSION WITH COMMUNITY
                    REPRESENTATIVES

Names and position of participants:
Date:
Moderator and secretary:


1. Situation of drug use
 Number, reported and estimates
 Proportion of injection
 Trend of drug use in the last five years, why?
2. Characteristics of drug users: age, sex, education, occupation, economic status
3. Drug use places: where, which location, why occurred in that areas, exist of drug
trafficking,
4. Factors facilitates the increase of drug use.
 Geographic, economic, social factors
 Job opportunity, mobility, urbanization
5. Point of view of community to drug users and care of them
 Local authorities, police, Sub-Department of Social Evil Control, mass
  organizations, drug use's families, people in the community
6. Review of interventions and policy on drug use and its health consequences,
effectiveness.
 IEC in the community, on street, at home, in schools...
 Increase job opportunities
 Law enforcement
 Drug treatment: Types (at home, at community, at district and in city treatment
  centers
 Harm reduction activities: who participate and effectiveness
            needles, syringes and condom provision
            STD treatment
            HIV testing and counseling
            health care for drug users
                                            88
          Social support
          peer education
 Policy for drug users
7. Recommendations for future intervention
 Prevent drug use
 Prevent HIV, HBV, HCV and others health problems




                                        89
Annex 5:
   CHECKLIST FOR FOCUS GROUP DISCUSSION WITH DRUG USERS


Names and position of participants:
Date:
Moderator and secretary:
1. Availability of drugs and use methods. Point of view of drug users on using
different drugs
 Kinds of drugs
 What drug used only by smoking
 What drug used only by injecting
 What drug used both by smoking and injecting
 Reasons for use of drug
 what drugs prefer most
 How to usr drug, in what way, why
 Where drug come from
2. Point of view of drug users on drug injection
3. Trend of drug use over time, when started to increase,
4. Characteristics of drug users: socio-economic background, sex, age, education,
occupation, income status, mobility
5. Process involving drug use:
 when started to use, in what age
 Duration to switch from smoking to injection
 Frequency of injection
6. Where drug users come from, where they live, where are shooting galleries and
   prostitution.
7. Social network of drug users: how they are divided in groups, based on what
characteristics (economic status, occupation, types of drug use, duration of drug
use...), relationship between groups in the city and with those from other provinces,




                                          90
8. Injecting risk behavior of drug users

Injecting Risk behavior of drug users      Percentage   In which group of drug users   Why (which factors: economic, cultural, social,
                                           estimates                                   policy and law)

   Sharing needles and syringes

   sharing drug solution containers

   having contaminated drug

   sharing between syringes

   sharing rinse water containers

9. Sexual risk behavior of drug users

Risk behavior of drug users                Percentage   In which group of drug users   Why (which factors: economic, cultural, social,
                                           estimates                                   policy and law)

   sex without using of condom

   multiple sexual partners

   sex with sex worker

   sex with drug users

   sex for drugs

   anal sex and other risk behaviors



                                                            92
10. Relationship between sex and drug, sex partners of drug users
11. Dug shock: situation and trends, occurred among what groups of drug users,
reasons of death due to drug shock (use multi drugs, injecting alone, types of drug
used, doses, way of using drug...
12. Characteristics of non-injecting drug users: socio-economic background, sex, age,
education, occupation, income status, mobility
13. The need of drug users
14. How to prevent health consequences of drug use such as HIV, HBV, HCV ...
among drug users




                                         93
                                  REFERENCES



1.    Direction Bureau of Drug control of Hanoi. Sum-up report on Drug control in
      the year 2000

2.    Direction of General Census about demography and housing. General Census
      on Demography and Housing in Vietnam, 1999, Result of sample investigation

3.    Ministry of Health. Estimation and Prediction of HIV infection in Vietnam
      2000-2005

4.    Ministry of Health. Annual Statistics, 1999

5.    UNDCP program of International drug control. Ministry of Labor, Invalid, and
      Social Affairs. Report on drug abuse in Vietnam, Hanoi January, 2000

6.    Sub-department of social evils control. Materials from Sum up Reunion in
      General Investigation on drug users in Hanoi, April 8, 1999.

7.    President of the Republic Socialist of Vietnam : Drug Control Code.

8.    President of the Republic Socialist of Vietnam : Penal Code. January 2000

9.    La thi Nhan, Ta tan Vu : Contribution to the evaluation of the prevalence of
      HBV and HCV infection among drug users at Thu duc Withdrawal Center,
      Hochiminh City, Medical Practice, N0 6, 1995

10.   Service of Labor, Invalid, and Social Affairs. - Sub-department of social evils
      control : Materials from Sum up Reunion in General Investigation on drug
      users in Hanoi, 1999

11.   Hanoi Health Service : Summary of statistic data, 1996-1998

12.   General Bureau of Tourism. The nation of Vietnam. Culture and Information
      Publishers, 2000

13.   General Bureau of Statistics : Annual Statistics, 1998. Statistics Publishers,
      1999

14.   UNICEF : Children on the World, 2001

15.   National Committee of AIDS and drug addiction and prostitution control.
      Documents of Sum-up Reunion of Program of Action in drug control, period
      1998-2000 and development of program of action in drug control period 2001-
      2005. Hanoi, May, 2001
                                         94
16.   National AIDS Committee. Report on cycle 1 supervision of behavior in
      Vietnam during the year 2000. Hanoi, May, 2001

17.   Municipal AIDS Committee of Hanoi. Report on the Study on Current situation
      of HIV infection and measures for HIV/AIDS control in Hanoi. December,
      1999.

18.   Executive Bureau of Drug Control National Committee. Report on the results
      of drug control in 2000.




                                      95
 HANOI MEDICAL                             HANOI AIDS
  UNIVERSITY                               COMMITTEE

          WORLD HEALTH ORGANIZATION




                       RAR REPORT

SITUATION ASSESSMENT OF DRUG INJECTING AND ITS
       HEALTH CONSEQUENCES AMONG IDUs
             IN HANOI CITY, VIETNAM



  Principal Investigator: Nguyen tran Hien, MD, MPH
                          Faculty of Public Health
                          Hanoi Medical University
                          Vietnam

                  Telephone: 84-4-8524141, Fax: 84-4-523 032,
                  Email: mph.hmcvn@hn.vnn.vn




                        Hanoi, 6/2001


                              96
                                 CONTENTS
    Executive summary                                              1

1   INTRODUCTION                                                   2

2   STUDY DESIGN                                                   3
    2.1 Objectives                                                 3
    2.3. Research team                                             3
    2.2 . Methods                                                  6
    2.2.1 Study geographical areas                                 6
    2.2.2 Study populations                                        6
    2.2.3 Data collection methods                                  6
    2.2.4 Training interviewers                                    7
    2.2.5 Study Organization                                       7
    2.2.6 RAR process                                              7
    2.2.7 Study plan                                               7

3   RESULTS                                                        10

    3.1     Contextual assessment                                  10
    3.1.1   Geographical, political and socio-economic situation   10
    3.1.2   Politic features                                       11
    3.1.3   Socio-economic features                                11
    3.1.4   Religion and belief                                    12

    3.2    Drug use                                                14
    3.2.1 Current situation of drug use in Vietnam                 14
    3.2.2 Current situation of drug use in Hanoi                   16
    3.2.3 Drug use policy in Vietnam                               28
    3.2.4 Viewpoint of community to drug users                     30

    3.3 Risk behaviors                                             33
    3.3.1 Drug use practice of drug users in Hanoi                 33
    3.3.2 Sexual practice of drug users in Hanoi                   38
    3.4 Health consequences of drug use.                           40
    3.4.1 HIV/AIDS situation in Vietnam                            40

                                      97
          HIV testing system                                      41
          HIV case reports                                        41
          AIDS case reports                                       45
          HIV Sentinel surveillance                               47

    3.4.2 HIV/AIDS situation in Hanoi                              54
    3.4.3 Viral hepatitis                                          61
    3.4.4 Drug shock                                               62
    3.4.5 Sexually transmitted diseases                            62
    3.4.6 Community opinions concerning drug use consequences      62

    3.5 Interventions among drug use population                    63
    3.5.1 Interventions among drug use population in Vietnam       63
    - Strategy for HIV infection control among drug users in
    Vietnam                                                        63
    3.5.2 Interventions among drug use population in Hanoi         65

    - Activities for prevention of drug use and drug criminality   66
    - Information-Education and Communication (IEC) activities     66
    - Drug treatment activities                                    70
    - Post-treatment management                                    71
    - Difficulties and constraints of drug control programs        71
    - Harm reduction activities for HIV prevention                 72
    - Point of view of community about harm reduction
    interventions.                                                 73
    - Difficulties and constraints of HIV/AIDS interventions       75

4   CONCLUSION AND RECOMMENDATIONS                                 77

    Annexes                                                        82
    References




                                       98
99