1. Evaluating a HIV Prevention Program AMONG People Who Inject Drugs in Southwest China Using Coarsened Exact Matching (CEM)
Kai Wang
Hongyun Fu
Kim Longfield
Shilpa Modi
Gary Mundy
Rebecca Firestone
Evaluation 2013
October 17, 2013

2. Overview of the Presentation
Background
Methods
Results
Conclusions

3. HIV/AIDs in Yunnan and Guangxi
1989: China reported first AIDS cases among 146 heroin users in Yunnan
Yunnan is located near the golden triangle.
The overall HIV prevalence in China is low (0.06%), however, the prevalence rates of HIV were among people who inject drugs (PWID) was 6.4%, with prevalence higher than 50% in parts of southwest China.
Yunnan and Guangxi Provinces account for 22% the total HIV cases in China despite making up only 6.9% of the national population in the country
New cases between Jan – Oct 2012: 68802, Sexual transmission accounts for 84.9% (homosexual transmission % relative to 15% in 2011)
HIV prevalence rates were 6.4% among PWID, 6.7% among among MSM, and 0.3% among FSWs in %
The reported HIV among PWID account for 87.2 of all total estimated HIV cases in China

4. Yunnan program sites map
HXH - PSI directly implements community-based IDU CPP interventions (including Drop-In-Center based and outreach activities and outreach into MMT clinics and communities) and provide TA to the community rehabilitation and recovery centers run by the local government
SAA – PSI, Pact and RTI provides capacity building to SAA to promote long-term sustainability of CPP interventions through local CBOs
Daguan, Lianmeng , Xiyuanliangyuan , Jinma CHC – member of the Clinical Health Network (CHN), which provide HIV, STI, TB, Hepatitis screening and counseling for MARPs, in collaboration with Kunming Municipal AIDS Bureau
Pact and RTI – Pact working with SAA to implement capacity development plans for 3 CBOs. RTI working with Yunnan Govt to operationalize the social Service Outsourcing (SSO) initiative
Yunnan program sites map
Poplar Tree - PSI providing TA and financial support to this IDU peer-led grassroots group to promote community based IDU CPP interventions
KUNMING
GEJIU
MENGZI
Kangxin Home – PSI provided TA and financial support to this IDU peer-led grassroots group to promote community based IDU CPP interventions – support completed December 2012

5. Background: Comprehensive HIV/AIDS Prevention Package (CPP) targeting MARPs
Policy
Stigma and Discrimination
Behavioral Change
Community Mobilization
HIV Counseling and Testing
STI Treatment
MARPs PLHA
Harm Reduction
Condom Distribution
Livelihood Development
Strategic Information
Linkages to Care and Support
Capacity Building 5

6. Methods Summary of method:
A behavioral tracking survey in 2012 (cross-sectional survey)
Face to face interview (self-report data)
Structured questionnaire
Yunnan Institute for Drug Abuse IRB Review
Respondent-driven sampling
1035 samples in four cities

7. Methods - Sampling Respondent-driven Sampling (RDS)
Seeds selection Criteria:
Age: <24; 24-40; >40.
Gender: Male; Female.
Current IDUs and Former IDUs.
Current MMT user and non-user.
Exposed; Non-exposed
Seeds Number:
8 seeds in Kunming; seeds in Nanning;
4 seeds in Gejiu; seeds in Luzhai.
Wave: 12 waves (the best seed)

8. Methods - Including Criteria
Study population: Participants were recruited from the social networks of PWID which were living in the local communities, and not residing in compulsory detox centers.
Aged (as measured according to the Western calendar and determined by participant self report)
Had injected drugs in past 12 months
Resident in the communities in either Kunming city, Gejiu, Luzhai or Nanning city for a minimum of 1 month.
Can speak and comprehend Mandarin to a sufficient level to respond to survey questions

9. Methods – Sample size In total: 1035 Gejiu 204 Kunming 336 Nanning 355
Luzhai
In total: 1035

10. Methods – Data Analysis
RDS weights
City weights
Coarsened Exact Matching (CEM) weights
Matching variables：1) Age; 2) Gender; 3) City 4); Working time (whether convenient to attend program activities); 5) Ever MMT use
Results: 975 cases matched /1035 samples,
L1 distance : 2.83 E-16
Logistic regression

11. Results: Population Characteristics
Sex (Male)
67.4%
Age (in years)
18-40
48.4%
41-49
51.6%
Ethnicity (Han)
83.3%
Education (High school education or above)
31.1%
Marital status
Never married
42.6%
Currently married or
57.4%
divorced or widowed
Ever received methadone maintenance treatment (MMT)
87.9%

12. Results: Behaviors outcomes

13. Results: Exposure to DiC and outreach

14. Results: Effectiveness of DiC and outreach
Never shared needles or syringes in past 3 months
Predictors
Matched sample:
(n=762)
Bivariate
Multi-variate
OR, 95% CI
Adjusted OR, 95% CI
Program exposure
Participated in DiC-based intervention in past 12 months
0.76
( )
( )
Participated in outreach in past 12 months
0.91
( )
1.04
( )
Ethnicity (Han)
---
0.39
( )
Education (High school education or above)
2.79*
( )

15. Results: Effectiveness of DiC and outreach
Kept a new needle on hand in past 3 months
Predictors
Matched sample:
(n=762)
Bivariate
Multi-variate
OR, 95% CI
Adjusted OR, 95% CI
Program exposure
Participated in DiC-based intervention in past 12 months
1.59**
( )
1.47*
( )
Participated in outreach in past 12 months
1.48**
( )
1.28
( )
Ethnicity (Han)
---
1.43
( )
Education (High school education or above)
1.13
( )

16. Results: Effectiveness of DiC and outreach
Tested for HIV in past 12 months
(Kunming)
(Gejiu, Nanning, and Luzhai)
Predictors
Matched sample:
(n=324)
(n=650)
Bivariate
Multi-variate
OR, 95% CI
Adjusted OR, 95% CI
Program exposure
Participated in DiC-based intervention in past 12 months
2.06**
( )
2.07**
( )
1.38
( )
1.17
( )
Participated in outreach in past 12 months
1.35
( )
1.19
( )
2.26***
( )
2.04**
( )
Ethnicity (Han)
---
2.04
( )
1.03
( )
Education (High school education or above)
1.60
( )
1.66*
( )

17. Results: Effectiveness of DiC and outreach
Consistent condom use with all partners in past 3 months
Predictors
Matched sample:
(n=500)
Bivariate
Multi-variate
OR, 95% CI
Adjusted OR, 95% CI
Program exposure
Participanted DiC-based intervention in past 12 months
2.26***
( )
2.29***
( )
Participated in outreach in past 12 months
1.68**
( )
1.38
( )
Ethnicity (Han)
---
0.66
( )
Education (High school education or above)
1.94***
( )
No. of Sexual behavior in past 3 months
0.97***
( )

18. Conclusion Peer-led programs reduced HIV risk among PWID.
The DiC-based activities in Yunnan and Guangxi were successful at increasing safe injecting practices, HTC, and consistent condom use.
Outreach coverage was low, especially in Guangxi province where the implementation model required building the technical capacity of government partners and grass roots organizations.
Outreach was most effective for referring PWID into HTC, and appears to increase awareness of DiCs where PWID can receive more intensive services and private HTC.
The CEM procedure improved the causal inference and gave stronger evidence for evaluating the impact.

19. Thank you! Questions?
PSI