1. TRENDS OF HIV PREVALENCE, NEEDLE SHARING, AND EXPOSURE TO HIV/AIDS INTERVENTION AMONG PWID IN VIETNAM: IBBS RESULTS Nguyen Anh Tuan NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY VIETNAM

2. Introduction It was estimated 255,000 PLWAs in Vietnam in 2015 with 14,000 new infections and 12,000 HIV/AIDS related deaths. More than 80% of PLWA was related to drug use and PWID Estimated number of PWID in 2015 is about 210,000 HIV epidemic in Viet Nam comprises many sub-epidemics across the country and remains concentrated among people who inject drugs (PWID), men who have sex with men (MSM) and female sex workers (FSW) The complexity of Vietnam’s HIV/AIDS epidemic need the data for routine, high-quality sero-prevalence and behavioral data related to: – Distribution, burden (e.g. incidence, prevalence), and changes in the epidemic and associated behaviors – Estimation of program ‘coverage’ and service uptake – Impact of key HIV/AIDS intervention programs on risk factors, transmission, and morbidity

3. HIV Surveillance System The first case HIV positive was detected in 1991. System of HIV/AIDS case reporting (1992): HIV/AIDS cases were reported from hospitals, clinics, provincial HIV/AIDS center, center for preventive medicine,... in all 63 provinces. System of HIV sentinel surveillance - HSS (1994) (now reaches 40 provinces) in People who inject Drug (PWID), Female Sex Worker (FSW), and Men who have Sex with Men (MSM) Behavioral Surveillance Surveys – BSS (in 2000 and 2001) in PWID, FSW, and mobile groups Integrated Behavioral-Biological Survey (IBBS) was implementing 3 rounds (2005, 2009, 2013) among PWID, FSW, and MSM in 12 provinces of the most serious epidemic in Vietnam

4. HIV Surveillance System System of HIV sentinel surveillance integrated with behavioral indicators (HSS+) was implemented in 2010 HIV incidence among the 6 sentinel groups were started in 2000. STI sentinel surveillance was starting in 2003 in 10 provinces HIV drug resistance surveillance was started in 2006

5. Estimated number of PLHIV in Vietnam, 1990 – 2020

6. Integrated Behavioral Biological Survey IBBSs were conducted 3 rounds in Vietnam (2005, 2009, 2013) Provided data to key stakeholders such as policy-makers, program managers, monitoring and evaluation officers, members of civil society, and development partners. Provided main data source in HIV/AIDS estimation and projection Primary objectives of IBBS are: – To provide representative provincial-level estimates of HIV prevalence (current and trends over time) in PWID, FSW, and MSM – To measure risk and preventive behaviors including sexual and drug- used behaviors as well as exposure to HIV/AIDS intervention programs

7. IBBS provinces

8. Organizational Involvement - Vietnam IBBS is a collaborative effort: Vietnam Authority for HIV/AIDS Control (VAAC) National Institute of Hygiene and Epidemiology (NIHE) Pasteur Institutes US Centers for Disease Control and Prevention (CDC) FHI360 Selected Provincial AIDS Centers. - Technical assistance by FHI, CDC, and USAID - Funding by PEPFAR

9. Cross-sectional surveys were conducted in 2005, 2009 and 2013 among male PWID across 09 provinces of Vietnam Biologic and behavioral data were collected to obtain – HIV/STI prevalence, – CD4 count, viral load – HBV, HCV prevalence – Risk and preventive behaviors on sexual and drug-used behaviors – Exposure to HIV/AIDS intervention programs Study Design

10. Collected Sample Size Province200520092013Sampling Method An Giang300 375RDS Can Tho299277515RDS Dien BienNA300500TLS Ha Noi296300500RDS Hai Phong301300400TLS Ho Chi Minh City296310500RDS Nghe AnNA300400TLS Quang Ninh266300420TLS Yen BaiNA360400TLS TOTAL1,7582,7472,3006,805

11. Sampling Method Is target population hidden and invisible? YES RDS NO Is estimated population size less than/or about equal to required sample size? YES Take-all method NO Is estimated population size about double the required sample size? YES Systematic Random Sampling NO Time location with two- stage cluster sampling or Venue-day time sampling

12. Laboratory Testing Strategy III of WHO was used for HIV positive confirmation Plasma samples were tested using an EIA test Genscreen Ultra HIV Ag/Ab (Biorad, US) for screening of HIV infection and confirmed by a rapid test [Determine HIV-1/2 (Alere, Japan)] and EIA test Murex HIV Ag/Ab Combination (DiaSorin, UK).

13. Statistical Analysis STATA 12 was used to obtain point estimates and 95% confident intervals for sample populations obtained through the TLS and take-all methods For TLS, sampling weights were calculated and applied to adjust for different sampling probabilities among participants. RDS Analyst 9.0 with successive sampling estimator (Gile’s estimator) was applied to all three rounds. In 2013, RDS Analyst was used for data analysis among PWID in only Ha Noi, Can Tho, HCMC, AnGiang. Point estimates and 95% confident intervals were calculated for the population estimates. Regression analysis and the Cochran-Armitage test were applied to test for statistical significance in trend among TLS and RDS samples, respectively, across 2005, 2009 and 2013.

14. Socio-Demographic Characteristics of PWID, 2013 CharacteristicAn GiangCan ThoHCMCHa NoiHai Phong Nghe AnQuang Ninh Yen BaiDien Bien Age, years (n)374427530500400 420399500 Mean27.131.731.835.034.930.834.837.433.7 Age group, years (n)374427530500400 420399500 < 2011.78.92.02.71.45.21.80.22.9 20 to<2534.319.08.613.38.021.86.77.312.6 25 to<3025.222.926.415.017.823.218.213.124.5 >=3028.849.263.069.072.849.873.379.460.0 Monthly income, million VND (n) 372427530500400389419390500 Mean3.24.25.03.98.03.53.2 3.3 Age at first drug use, years (n)374427530500400386419372496 Mean20.822.420.524.023.722.524.726.323.1 Duration of drug use, years (n)374426508473400386419372496 Mean6.28.711.0 11.38.310.110.710.5 Duration of injection drug use, years (n) 374426530500 400389418376496 Mean5.77.08.27.97.76.57.87.75.6

15. Used Substance, 2013 Data source: IBBS 2013

16. HIV Prevalence Trends, 2005-2013

17. HIV prevalence, 2013

18. Trends in Needle Sharing in past 6 months, 2005-2013

19. Sex with Different Partners in Past 12 Months, 2013

20. Consistent Condom Use with Different Sex Partners in Past 12 months, 2013

21. HIV Testing and Received Results in Past Year, 2005-2013

22. Receiving Free Clean Syringes/Needles in Past Month, 2013

23. National HIV prevalence among MARP, Vietnam 1990 – 2020

24. Distribution of New HIV Infections in Vietnam 2005 – 2020: Medium scenario

25. Summary In general: Overall trend of HIV prevalence were decreasing overtime, but still in high prevalence (10.3-43.5%) Overall trend of sharing needles and syringes in the past six months were decreasing Overall trend ever voluntarily tested for HIV over time were increasing Overall trend having HIV voluntarily testing and receiving results in the past year were increasing in 4 (HN, QN, HCMC, CT), decreasing in 2 (HP, DB), and did not find difference in 3 (NA, YB, AG) Success in controlling the HIV epidemic among PWID will depend on their continued assess to clean needles/syringes and voluntary HIV testing.

26. Thank you!